EFFECTS OF QIGONG ON PERFORMANCE RELATED

ANXIETY AND PHYSIOLOGICAL STRESS FUNCTIONS IN

TRANSVERSE FLUTE MUSIC SCHOOLCHILDREN

A feasibility study

CLUDIA MARIA GOMES DE SOUSA

Master thesis of Traditional Chinese Medicine

2011
CLUDIA MARIA GOMES DE SOUSA

EFFECTS OF QIGONG ON PERFORMANCE RELATED ANXIETY

AND PHYSIOLOGICAL STRESS FUNCTIONS IN TRANSVERSE
FLUTE MUSIC SCHOOLCHILDREN

A feasibility study

Master thesis proposal in Traditional

Chinese Medicine (TCM) submitted to
Instituto de Cincias Biomdicas de
Abel Salazar Universidade do Porto.

Supervision Henry J. Greten

Category Associated Professor
Affiliation Instituto de Cincias
Biomdicas Abel Salazar -
Universidade do Porto.

Co-supervision Jorge P. Machado

Category Associated Professor
Affiliation Instituto de Cincias
Biomdicas Abel Salazar da
Universidade do Porto.

Co-supervision Mario J. Gonalves

Category TCM - Qigong Specialist
Affiliation Heidelberg School of
Chinese Medicine.
 Master Thesis 2011

Resumo

Reviso da literatura: Os transtornos de ansiedade so condies psiquitricas

comuns que podem causar diminuio da qualidade de vida e enormes custos sociais.
Algumas estatsticas indicam que um em cada trs pacientes que sofrem destes
transtornos apresenta uma resposta insuficiente aos tratamentos convencionalmente
usados na medicina ocidental. Os distrbios de ansiedade esto estreitamente
correlacionados com a facilidade de aprendizagem. As alteraes vegetativas que
acompanham os sndromes de stresse podem tambm influenciar negativamente as
capacidades funcionais dos indivduos. Exemplo disto so os msicos que necessitam
de um aprimorado controlo motor e respiratrio. Nos flautistas a ansiedade pode
potencialmente causar problemas que empiricamente incluem ansiedade, batimento
cardaco e presso arterial acelerados, tenso muscular e mos frias.

Objetivo do estudo: Este estudo pretende investigar se e como os efeitos fsicos e

psicolgicos relacionados com a prtica de Qigong podem ser objectivamente
medidos. Para isso as medies de determinados parmetros sero realizadas em
alunos de flauta transversal, com idades compreendidas entre os 10 e os 12 anos,
antes de audies.

O presente estudo considerado como um primeiro passo para a criao de

desenhos de estudo objetivos a serem sistematicamente planeados, com base na
mensurabilidade dos efeitos relacionados com o Qigong. At data no foram
encontrados quaisquer estudos cientficos sobre a ansiedade relacionada com o
desempenho. Alm disso, o exerccio da bola branca empiricamente considerado
altamente eficaz, mas nunca foi cientificamente examinado para esta finalidade. A
principal vantagem deste tipo de Qigong reside no facto de um ciclo de exerccios
durar apenas alguns minutos e requerer pouco movimento e espao, o que permite a
sua integrao numa aula regular, sem perda significativa do tempo de ensino.

Mtodos: Estudo prospectivo com controlo (lista de espera).

Parmetros principais: EADS-C e cortisol salivar.

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 Master Thesis 2011

Parmetros secundrios: frequncia cardaca, presso arterial, eletromiografia de

superfcie e tempo de reao (medido pela resposta a estmulos por MP36 Sistemas
Biopac).

A termografia permite a medio do fluxo capilar das mos antes e depois da

sequncia de exerccios de Qigong. Durante o desenvolvimento do estudo foi
demonstrado que a termografia pode ser uma ferramenta til para estudar
objetivamente os efeitos relacionados com o Qigong. Em cooperao com o projeto de
mestrado de Lus Matos, foi medida a termografia dos braos e pernas dos
participantes no incio do estudo e aps 7 semanas.

Critrios de incluso: Alunos de flauta transversal com idades compreendidas entre os

10 e os 12 anos, capazes de seguirem as instrues requeridas para a prtica de
Qigong, depois de assinarem o termo de consentimento informado.

Os critrios de excluso: Problemas psicolgicos graves e experincia prvia com

Qigong.

Interveno: 8 crianas receberam aulas de Qigong (exerccio da bola branca)

durante 30 minutos, ao longo de 7 semanas, 2 vezes por semana, sendo que tambm
foram instrudas para fazerem os exerccios diariamente em casa. O grupo de
controlo, constitudo igualmente por 8 crianas, no recebeu qualquer interveno
(lista de espera).

Resultados: Os resultados demonstraram que o Qigong reduz:

a perceo subjetiva de ansiedade (4,5 pontos) (medida pela EADS-C);

a frequncia cardaca (11 batimentos por minuto);

a presso arterial (6,54 mmHg);

os nveis de cortisol salivar (0,198 g/dl) em alunos de flauta transversal antes

de audies.

Apenas a diminuio da frequncia cardaca foi significativa para um = 0,05

(valor de p=0,005). Em contrapartida no h evidncias de que Qigong eficaz na

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reduo da tenso muscular do trapzio (medida pelo SEMG) e na reduo do tempo

de reao.

A termografia, como uma avaliao funcional objectiva em tempo real, mostrou

ser uma ferramenta importante para medir os efeitos do Qigong (dados apresentados
na dissertao de mestrado do engenheiro Lus Matos).

Discusso: O estudo confirma que os efeitos relacionados com o Qigong podem ser
convencionalmente objetivados por valores psicolgicos e parmetros fisiolgicos,
incluindo medies de cortisol salivar. O estudo revela que 2 novos parmetros
(EADS-C e fluxo capilar medido por termografia) podem ser escolhidos para medio
dos efeitos do Qigong. Revela ainda que o batimento cardaco, a tenso arterial e o
nvel de cortisol salivar so parmetros objetivos que permitem medir os efeitos do
Qigong na ansiedade relacionada com o desempenho.

Surpreendentemente e embora o tamanho da amostra seja n=8/8, os dados

mostram alteraes estatisticamente significativas ao nvel do batimento cardaco.
Futuramente seria conveniente aumentar o tamanho da amostra, de forma a aumentar
o poder estatstico dos dados.

Um dos principais problemas dos estudos de Qigong e de interveno

psicolgica a escolha dos controles adequados. Neste estudo piloto concentramo-
nos na mensurabilidade dos efeitos. Futuramente o controlo escolhido poder ser
substitudo por um plano baseado na realizao de qualquer outro tipo de exerccios
de Qigong, por uma actividade de lazer ou outros. Aleatoriedade e participantes cegos
devem ser fatores a incluir num futuro estudo.

Concluso: Os efeitos do Qigong podem ser medidos objetivamente atravs de

parmetros psicolgicos e fisiolgicos como o cortisol salivar. Este estudo refere 2
novos parmetros objectivos que podem ser usados na realizao de um novo estudo
sobre os efeitos do Qigong (bola branca) nos distrbios fsicos relacionados com a
ansiedade.

Palavras-chave: Qigong, efeitos do Qigong, Medicina Tradicional Chinesa, ansiedade,

ansiedade relacionada com o desempenho, stresse, alunos de msica, o modelo de
medicina tradicional chinesa de Heidelberg.

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 Master Thesis 2011

Abstract

Background: Anxiety disorders are common psychiatric conditions that can cause
significant disability, poor quality of life and enormous social costs. Studies showed that
one out of three patients suffering from anxiety shows insufficient response to
standardize western treatment. Anxiety and improvement of learning are closely
related. Vegetative changes as seen in stress syndrome may also impair functional
abilities of the patients. This is frequently seen in musicians who require an ultimate
motor and breathe control. In flutists performance-related anxiety may potentially cause
problems that empirically include anxiety, heartbeat, blood pressure, muscular tension
and cold hands.

Aim of the study: This study aims to evaluate if and how Qigong-related effects may
be further objectified by physical measurable parameters and psychological scores. For
this propose we examined 10 12 year old music school children playing the
transverse flute before auditions.

This is regarded as a first step towards the creation of objective study designs
to be systematically planned on the basis of measurability of Qigong related effects. To
our knowledge, there are so far no scientific studies on performance related anxiety
and Qigong at all. Furthermore, the exercise system of the white ball is empirically
highly effective, but was so far never scientifically examined for this purpose. The main
advantage of this system is the fact that an exercise cycle only takes a few minutes
and requires only little movement and space, so it could be integrated in class-teaching
without significant loss of teaching time.

Methods: Prospective controlled interventional study with waiting list design.

Main parameters: EADS-C and salivary cortisol.

Side parameters: Heart rate, blood pressure, surface electromyography, time reaction
(measured by stimulus response situation by MP36 BIOPAC Systems).

Thermography allows the measurement of capillary flow of the hands before

and after training sequence. During the development of the study, it was shown that

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thermography may be a useful tool for objectifying Qigong related effects. In

cooperation with the master project of Luis Matos, thermography of the arms and legs
was additionally measured at the beginning of the study and after 7 weeks.

Inclusion criteria: Music school children of 10 - 12 years of age playing the transverse
flute, capable of following the Qigong instructions in terms of Portuguese language
skills, after having signed the written consent.

Exclusion criteria: Major psychological problems and previous experience with Qigong.

Intervention: In the Qigong group 8 children were included and they received specific
Qigong lessons of the so-called white ball Qigong over 7 weeks, twice a week, for 30
minutes. They also were instructed to do the exercises at home daily. In the control
group 8 children were included and they didn`t receive any intervention (waiting list
design).

Results: Qigong reduced

subjective perception of anxiety (mean of 4.5 as measured by EADS-C);

salivary cortisol levels (mean of 0.198 g/dl);

heart rate (mean of 11 beats per minute);

blood pressure (6.54 mmHg) in transverse flute schoolchildren before auditions.

However, only heart rate decrease showed a significant change for an =0.05
(p value=0.005). There is no evidence that Qigong is effective in the reduction of
muscular tension of trapezius (measured by SEMG) and in the reduction of time
reaction.

Thermography as a real time objective functional assessment showed to be an

excellent tool for Qigong studies with highly significant measurability (data presented
within the master thesis of the engineer Luis Matos).

Discussion: The study confirms that Qigong related effects may be conventionally
objectified by psychological scores and physiological parameters including cortisol
measurements.

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In addition the study reveals that 2 new parameters can be chosen such as
EADS-C and capillary flow as measured by thermography. The study also reveals that
heart rate, blood pressure and salivary cortisol are objective parameters to measure
the effects of Qigong on performance related anxiety

The data surprisingly show statistically significant changes, although the sample
size is n=8/8. The data suggests to enlarge the sample size. For future studies further
statistical power analysis is necessary.

It is a principal problem of Qigong research and psychological intervention to

choose adequate controls. In this pre-study we focused on measurability of the effects.
The control chosen here (waiting list design) may be changed to either another type of
Qigong, to another occupation or others. Proper randomization and blinding
procedures should be carried out to develop an objective study design.

Conclusion: Qigong effects can be measured properly by psychological scores and

physiological parameters such as salivary cortisol. This study shows 2 new objective
parameters that may be used to further document, the obvious effects of the white ball
Qigong on performance related anxiety and related physical disorders as measured in
this study.

Key words: Qigong, effects of Qigong, Traditional Chinese Medicine, anxiety,

performance related anxiety, stress, music school children, Heidelberg Model of TCM.

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Aos meus pais

que so imensamente responsveis pelo que eu sou at hoje

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Acknowledgments

Prof. H.J Greten, Prof. Jorge P. Machado and Mario Gonalves for all the
supervision.
Dr. Manuel Lima and Jos Gomes for technical assistance.

My mother Idilia Conceio, my dear friend Jos Gomes, my sister Joana

Sousa, my cousin Catarina Gomes, my aunt Angela Santos for all support and help in
all events.

Raquel Ribeiro (Academia de Msica e Artes de Riomeo), Isabel Castro

(Academia de Msica de Paos de Brando) and to all the children and their parents,
because without them this wouldn`t be possible.

My uncle Mrio Cardoso (Cardoso e Conceio) for lending the auditorium

where the auditions where done.

Carla Rodrigues my transverse flute teacher, for the support and for all the
things she taught me.

Hospital de Santo Antnio and Dr. Jos Carlos for the help in the measurement
and analyses of salivary cortisol level.

Dr. Rui Magalhes for the help in the statistics.

My aunt Gloria Silva who helped me with my English.

Andreia Fernandes my dear friend, for all the support.

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Abbreviations

ANA Autonomic Nervous System

BP Blood Pressure

DASS - Depression Anxiety and Stress Scale

Dr. - Doctor

EADS C Escala de Ansiedade, Depresso e Stresse para Crianas, de Lovibond e

Lovibond

EMG Electromyography

e.g. for instance

HR Heart Rate

IEMG Intramuscular Electromyography

Pc Pericardium

PNS Parasympathetic Nervous Systems

Prof. Professor

R Renal

Rg Regens

RAAS - Renin Angiotensin Aldosterone System

SD Standard Deviation

SEMG Surface Electromyography

SNS Sympathetic Nervous System

TCM Traditional Chinese Medicine

TR Time Reaction

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Index

Introduction ................................................................................................................... 1

1. State of Art............................................................................................................. 3

1.1 Anxiety and music schoolchildren .................................................................. 3

1.2 Traditional Chinese Medicine and anxiety ....................................................... 6

1.3 Qigong effects in the language of TCM ......................................................... 22

1.4 Measurable and hypothetic effects of Qigong ............................................... 23

2. Study design ........................................................................................................ 31

2.1 Investigation question and aim of the study ....................................................... 31

2.2 Objectives ......................................................................................................... 31

3. Methods ............................................................................................................... 32

3.1 Recruitment ....................................................................................................... 32

3.2 Intervention ....................................................................................................... 33

3.3 Measurements................................................................................................... 36

3.4 Statistical analysis ............................................................................................. 43

4. Ethical Consideration .......................................................................................... 44

5. Results ................................................................................................................ 45

5.1 Data .................................................................................................................. 45

5.1 Statistical Analysis ............................................................................................. 47

6. Discussion .......................................................................................................... 54

7. Conclusion .......................................................................................................... 60

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8. Final considerations ............................................................................................ 62

9. References ......................................................................................................... 63

1st Annex: Schedule .................................................................................................... 68

2nd Annex: Literature review ........................................................................................ 69

3rd Annex: EADS-C ..................................................................................................... 78

4th Annex: Declaration of Informed consent ................................................................ 80

5th Annex: Ethical permission ...................................................................................... 82

6th Annex: Results ....................................................................................................... 85

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Illustration index

Figure 1 - Synopsis of the complex diagnosis in TCM. .................................................. 7

Figure 2 - The left part of the picture shows how yang lines (white) and yin lines (black)
can be used as monograms ........................................................................................ 11

Figure 3 - Water basin model ...................................................................................... 12

Figure 4 - Movements of the hand of a pipe organ player 13

Figure 5 - Phases ....................................................................................................... 14

Figure 6 - Phases ....................................................................................................... 16

Figure 7 - Hepatic orb, the emotional expression is referred to as ira.......................... 18

Figure 8 - Cardiac orb, the emotional expression is referred to as voluptas ................ 19

Figure 9 Pulmonary orb, the emotional expression is referred to as maeror ............. 20

Figure 10 Renal orb, the emotional expression is referred to as timor ...................... 21

Figure 11 - Mean and standard deviation of subjective perception of anxiety .............. 48

Figure 12 - Mean and standard deviation of heart rate ................................................ 49

Figure 13 - Mean and standard deviation of blood pressure values ............................ 50

Figure 14 - Mean and standard deviation of surface EMG .......................................... 51

Figure 15 - Mean and standard deviation of time reaction ........................................... 52

Figure 16 - Cortisol levels ........................................................................................... 53

Table 1 - Percentage of days and assiduity to Qigong classes45

Table 2 - Difference between the 1st and the 2nd measurements (Qigong group) ...... 46

Table 3 - Difference between the 1st and the 2nd measurements (control group) ....... 46

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Introduction

The present work is a thesis proposal within the framework of the Master
degree of Traditional Chinese Medicine, lectured in Instituto de Cincias Biomdicas
de Abel Salazar University of Porto, under supervision of Prof. Henry Johannes
Greten and co-supervision of Prof. Jorge Machado and Qigong Specialist Mrio
Gonalves.

Anxiety disorders are common psychiatric conditions that can cause significant
disability, poor quality of life and enormous social costs (Menezes et al., 2007). To treat
anxiety, western medicine uses drugs such as benzodiazepines, buspirone,
antidepressives, beta-blocking agents, antipsychotics and others (Andreatini, Lacerda
and Filho, 2001). According to Menezes et al. (2007), a great number of patients fail to
respond or remains with clinically significant residual symptoms after conventional
treatment. According to the same authors one out of three patients shows insufficient
response or does not get better with standard western treatment. Andreatini, Lacerda
and Filho (2001) also affirm that in Brazil, just 50% of patients with anxiety disorders
are successfully treated by western drugs.

Traditional Chinese Medicine is defined as a system of sensations and findings

designed to establish a functional vegetative state which can be treated with
acupuncture, Qigong, tuina, Chinese pharmacology and dietetics (Greten, 2010).The
word Qigong is the combination of the words Qi and qong. According to the Heidelberg
model, Qi is the vegetative capacity to function of a tissue or an organ which may
cause the sensation of pressure, tearing or flow. Qi is also called the vital energy" of
the body (energy is defined as the capacity to work), and gong is the capacity to work
with the Qi. Although it is used by millions of people, the scientific proof of Qigong
related effects is poor for several reasons:

1. The effects are difficult to objectify: Besides psychological scores, salivary

cortisol has been successfully used. It was also shown that patients with
migraine and high blood pressure may profit from Qigong, but the studies do
not reach scientific standards due to poor evaluation, lack of controls, or
anecdotal type of data.

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2. The Qigong methods are not properly and uniformly defined: The indications
of the exercises only rarely allocated to western diagnoses, their details not
sufficiently explained. In fact, Qigong does not equal Qigong, as there are
more than 1000 styles officially taught (Li, Chen and Mo, 2002).

3. Insufficient controls: One can say that there is a general problem to create
controls in psychotropic exercises such as Qigong, psychotherapy or yoga.

4. Insufficient blinding.

It is the purpose of this pre-study to address to the measurability of Qigong

related effects. It uses the style of the white ball to overcome the problem of the
definition of the exercises, as well as the allocation of exercises to clinical conditions.
It does not focus on the problems of controls and blinding.

This study aims to evaluate if and how Qigong related effects may be further
objectified by physical measurable parameters and psychological scores. For this
propose we examined 10 12 year old music school children playing the transverse
flute before auditions.

It should be taken into consideration the great difficulties to train and to

convince adequately the children in order to participate in this study with a correct
sequence and performance in Qigong practice. In the followed sessions it will be
presented the state of art, study design, methods, ethical consideration, results,
statistical analysis, discussion and the final considerations.

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1. State of Art

For this literature review, we searched on data bases such as b-on, Pubmed,
Science Direct and Google Scholar. We used the key words Qigong, effects of Qigong,
Qigong for schoolchildren, medical effects of Qigong, Traditional Chinese Medicine,
anxiety in children, stress in children, and others.

This review will be divided into four different parts: first we will refer some important
data about anxiety in children and music teaching in Portugal, then we will define some
essential concepts of Traditional Chinese Medicine according to the Heidelberg model,
and after that we will talk about Qigong in particular and its effects.

1.1 Anxiety and music schoolchildren

1.1.1 Anxiety, depression and stress

Anxiety is defined as a manifestation of somatic tension and arousal with
symptoms such as shortness of breath, feeling dizzy, dry mouth, trembling or shaking
(Watson et al.1.2, 1995). During childhood and adolescence anxiety is normal and
allows the adaptation of the child/teenager to new and unexpected situations. Most of
the children can deal with anxiety in a healthy way, since the anxiety is a transitory and
a functional experience. However, if the child cannot cope with anxiety correctly,
anxiety may become unhealthy and chronic. If, according to Wilson, Pritchard and
Revalee (2005) (in Borges et al., 2008) children and teenagers can`t deal with anxiety,
they could present different with various depressive and anxious symptoms that could
disturb their individual, familial and social development as well as their development at
school. Anxiety disorders are common psychiatric conditions that can cause significant
disability, poor quality of life and enormous social costs (Menezes et al, 2007).

To treat anxiety, western medicine uses drugs such as benzodiazepines,

buspirone, antidepressives, beta-blocking agents, antipsychotics and others
(Andreatini, Lacerda and Filho, 2001). According to Menezes et al. (2007), western
medicine can`t solve all cases of anxiety disorders since a great number of patients fail
to respond or remain with clinically significant residual symptoms after the treatment.

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Statistics show that one out of three patients presents an insufficient response or does
not get sufficiently better with standard western treatments.

Kessler and his colleagues (2001) have done a study to describe the use of
complementary and alternative medicines to treat anxiety and depression in the United
States. According to their work 9.4% of total participants reported suffering from anxiety
attacks in the past 12 months and 7.2% reported severe depression. A total of 56.7%
of those with anxiety attacks and 53.6% of those with depression reported using
complementary and alternative therapies to treat these conditions during the past 12
months. The authors concluded that complementary and alternative therapies are
used more than conventional therapies by people with self-defined anxiety attacks and
severe depression. The perceived helpfulness of these therapies in the treatment of
anxiety and depression was similar to that of conventional therapies.

As said before, anxiety is defined as a manifestation of somatic tension and

arousal with symptoms such as shortness of breath, feeling dizzy, dry mouth, trembling
or shaking. In contrast, depression is defined as an absence of positive emotional
experiences with symptoms such as feeling disinterested in things, lack of energy,
feeling that nothing is enjoyable and that nothing in life has fun. However studies show
that anxiety and depression are strongly correlated (Watson et al.1,2, 1995).

Watson et al.1,2 (1995) developed a tripartite model of depression and anxiety

that divides symptoms into 3 groups: symptoms of general distress that are largely
nonspecific, manifestations of anhedonia and low positive affect that are specific to
depression, and symptoms of somatic arousal that are relatively unique to anxiety.
The authors concluded that anxiety and depression are strongly related. According to
them, anxiety and depression states show nonspecific symptoms of general distress.
This nonspecific group includes anxious and depressed states, as well as other
symptoms such as insomnia, restlessness, irritability, poor concentration, that are
prevalent in both types of disorder. In the tripartite model, these nonspecific symptoms
are primarily responsible for the strong association between measures of anxiety and
depression (Watson et al.1,2, 1995).

Cole et al. (1998) have done a study in France, aimed to investigate the relation
between anxiety and depression levels in children and adolescents. 330 students and
their parents (n=228) participated in a 3 year longitudinal study and every 6 months
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completed depression and anxiety questionnaires (Children's Depression Inventory,

Revised Children's Manifest Anxiety Scale). The results show that high levels of anxiety
predict high levels of depression in children and adolescents. This result supports the
hypothesis done by Watson et al.1,2 (1995).
Borges et al. (2008) have done a study in Portugal to measure the levels of
anxiety and coping of teenagers and children and their relation with age and gender.
For that they studied 916 children and teenagers from different Portuguese schools.
They used the multidimensional anxiety scale for children and the coping responses
inventory- youth form to measure the results. The results show that children between
10 and 13 years old show more anxiety in some aspects like separation and fear of
being alone in strange situations. In the other hand girls show more anxiety than boys
in aspects like tension, somatic symptoms, perfectionism, fear of failing, separation,
and anxiety in general. Also the use of complex coping strategies increases with age.
Older children also become more independent and they don`t need parents support to
solve their problems.
According to the same authors, anxiety increases with a stress situation.
Because of that, the evaluation of anxiety has to be careful and has to consider all the
environment of the children. According to Rijavec and Brda (2002), and with Skinner
and Wellborn (1997) (in Borges et al., 2008) there are some situations that could cause
stress in children like problems at school and problems with family and friends. In case
of teenagers the result of tests, school pressure, problems at school, and the authority
of their parents can be effective stress causes.

1.1.2 Music teaching in Portugal

In Portugal the teaching of music has been growing in the last years. One of the
main problems of the professional musicians and music school children is to deal with
the anxiety and stress before the auditions and concerts.

Anxiety and improvement in learning are closely related. Vegetative changes as

seen in stress syndrome may also impair functional abilities of the patients. This is
frequently seen in musicians who require an ultimate motor and breath control. In
flutists anxiety may potentially cause problems that empirically include, heartbeat,
blood pressure, muscular tension and cold hands.

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 Master Thesis 2011

Studies suggest that Qigong, a traditional vegetative biofeedback therapy, might

help to relax mind, muscles, tendons, joints and to change body functions (Sancier,
Hole, 2001). This leads to the assumption that Qigong may be a helpful method to
decrease the levels of stress and anxiety in music school children.

1.2 Traditional Chinese Medicine and anxiety

1.2.1 TCM according to the Heidelberg model

Traditional Chinese Medicine is defined as a system of sensations and findings
designed to establish a functional vegetative state which can be treated with
acupuncture, Qigong, tuina, Chinese pharmacology and dietetics. Acupuncture is
based on the use of needles to stimulate some points of a conduit, tuina is the Chinese
manual therapy, Chinese pharmacology is the use of plants to treat a vegetative
functional state and dietetics is the use of food and nutrition to treat a determined
condition (Greten, 2010). Qigong as we have said before is the combination of the
words Qi and gong. Qi is defined as the vital energy and gong is the capacity to work
with the Qi.
According to the Heidelberg model Traditional Chinese Medicine, like all other
medicines, interprets symptoms. However the postulates on which the symptoms and
the body functions are interpreted differ to a certain degree from western medicines.

1.2.1.1 The diagnose

The following overview of the diagnostic structure of TCM is adopted material
from Understanding TCM (ISBN 978 3 939087 07 6) (Greten, 2010). Anxiety is mainly
understood as a part of a deregulation functional pattern leading to sensitivity to cold,
stiffness, loss of motoric power, and joint problems.

As we can see in figure 1, there are four parts of a diagnose:

- Constitution,

- Pathogenic factor (agent),

- Organ patterns (orb),

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- Guiding criteria

Figure 1 - Synopsis of the complex diagnosis in TCM. This diagnostic system is based on a
mathematical consideration by Leibniz, which uses the terms yang and yin as a binary
numbering code (Greten, 2010)

The constitution is a part of the diagnosis which defines the inner nature of the
person as an expression of its physical appearance. This shows that Chinese Medicine
has the concept that physical structure changes the functional behaviour of man,
therefore his feelings, functions and the probability of certain symptoms. This is not
much different to classical Greek descriptions of analogue characters like the choleric,
sanguine, melancholic or phlegmatic. Nevertheless, these descriptions are not at all
identical though analogous.

The pathogenic factor, the so-called agent, is what makes us sick. It is a

functional power (Qi) which offends the pre-existing constitutive functional behaviour. In
other words, the person is in his normal constitutive behaviour but something affects
him which is called the pathogenic factor. This offence directly results in the affection of
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 Master Thesis 2011

some parts of the body and therefore produces actual, recent and sometimes different
symptoms which are believed to be abnormal and thereby sick by the patient. In other
words an agent is a pathogenic factor eliciting specific signs and symptoms.

Agents can be divided into neutral, exterior and inner agents. Neutral agents
are for example overwork, overeating, malnutrition and others.

Exterior agents include humor, algor, ventus, and others.

Humor is described as signs and symptoms as if you had been exposed to

environmental humidity, such as swollen limbs and tissues, feeling of heaviness,
dyspnea, generalized pain, and others. From a western medical view, these sign may
originate from pre-edema and edema (Greten, 2010).

Algor is described as signs and symptoms as if you had been exposed to

environmental cold, such as cold skin, stiff muscles, tearing and localized pain with
gradual onset. From a western medical view, these signs may originate from regional
deficiencies of capillary blood flow (Greten, 2010).

Ventus is described as signs and symptoms as if you had been exposed to a

draught of air, such as running nose and eyes, reddish mucosa, swollen tonsils, spastic
muscles, pain with sudden onset. From a western medical view, these signs may
originate from mast cell-substance P reflexes and old reflexes of motor control as
known from fish and other species (Greten, 2010).

Examples of interior agents are emotions such as

- ira (anger),

- voluptas (lust),

- pavor (shock),

- maeror (grief),

- timor (anxiety),

- cogitation (exaggerated thinking and mental effort).

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 Master Thesis 2011

Anxiety, as an example, is allocated to the internal pathogenic factors. It may lead

to a vegetative deregulation which consists of cold sensations, weak legs and tremor,
loss of motor control etc.

The orb is the third major constituent of Chinese diagnosis. This word refers to the
Latin word orbis which means circle. It is a circle or group of diagnostically significant
signs and findings that are grouped and named after organs or the region where some
of the symptoms take place. Sometimes this is referred to as the Chinese organ
teaching which is a simplified understanding of the system.

In fact, an orb is only a group of diagnostically significant signs that include possible
symptoms in the region of a western organ. This is why the correlation of western
organs and Chinese orb names is relatively loose. One could therefore name this an
organ-named functional pattern rather than an organ. For instance, the pulmonary orb
refers to signs and symptoms that are related to the motion that we call expiration.
While this respiratory movement takes place within the body, vegetative functional
changes appear like changes in muscular tone, changes in immune functions like
flooding capillaries in different capillary beds, like letting return the blood to the heart
during inspiration (negative pressure in the chest). So the signs differ a lot from airway
infections in many cases.

After defining these symptoms as constitution-related, factor-related and resulting

pattern-related, the symptoms are then interpreted in the context of the whole body
regulation by the so-called eight Guiding Criteria. These Guiding Criteria can be
understood as the teaching of body regulation:

1- Repletion and depletion (fullness and emptiness) in a western understanding

refer to the functional capacity mostly induced by the vegetative system;

2- Calor and algor (heat and cold) represents the humoro-vegetative regulation
since calor is an increased microcirculation with inflammatory effects and algor
a decreased microcirculation with lack of inflammatory effects;

3- Extima and intima (outside and inside) refer to the neuro-immunological

regulation;

4- Yin and yang.

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1.2.1.2 The guiding criteria are based on Yin, Yang, the phases and orbs

Changes in the functional capacity result in visible signs that add to the creation
of the findings and symptoms. This teaching is not coincidentally formed but that
the origin of this teaching may be a precise logical system based on a numbering
system of yin and yang.

The famous mathematician Leibniz analysed the oldest book of mankind, the I
Ging. This book is believed to date back at least 3,000 years and according to some
other sources the origins date back 5,000 years. This is the oldest book of China and
mankind and it was designed to systematically describe the course of life, its changes,
its modalities, and it would offer advice to our personal and emotional life-style and
personal guidance. Therefore, it was described as the Book of Changes. The book was
translated in an admirable way by a missionary, a theologian from Germany, called
Richard Wilhelm and it was published in 1923. Ever since, this has evoked the curiosity
of the European and American users and thinkers.

Leibniz though, 300 years before, found out that the bars and symbols in this book
have a mathematical meaning far from philosophy. On this binary numbering system
Booles algebra and other bases for computer and knowledge of nowadays are based.
Leibniz also showed the rules, the arithmeticae binariae and the ways to calculate with
these binary numbers. He built the first calculator of Germany in 1643.

To give a short description what Leipniz found, we changed the lines and symbols
of the I Ging into white and black bars. Within the I Ging the white bars are continuous
bars, meaning yang, whereas the black bars are discontinuous bars and mean yin. To
make it more visible and for practical reasons we reduced this to black and white bars.

Mainly we can see that in the first line one of these graphs (a monogram) means 1
or 0, so we can develop the numbers 1 or 0 out of these bars. The second line shows
bigrams, or two-lined symbols, which means that we can develop the numbers 1 to 4
out of two yin-yang lines. Accordingly, out of three of these lines, a trigram, we can
develop the numbers 1 to 8. In classical Chinese natural sciences and philosophy also
these binary numbers were used to describe circular movement such as shown in the
Figure 2.

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 Master Thesis 2011

Figure 2 - The left part of the picture shows how yang lines (white) and yin lines (black) can be
used as monograms (1 and 0), bigrams which compose two lines to form 1,2,3,4, or even
trigrams (1-8) (Greten, 2010)

Instead of writing 1, 2, 3, 4 they would use the bigrams to symbolise the quarter
sections of a circular movement. For instance, such a movement is the circular process
of the seasons spring, summer, autumn and winter. It could also be used for other
circular processes like the day or functional behaviour of man. Within the 3rd century
before Christ these bars were more and more exchanged by the symbols and emblems
for Wood, Fire, Metal and Water.

We can describe four parts of a circular procedure by bigrams, but we can also
have a more precise description of circular functions by trigrams. Instead of quartering
the circle, we would have 1/8th of the process as one part of the process.

1.2.1.3 Why are circular functions so important for medicine?

To explore how yin and yang and circular functions are important for medicine,
we refer to a simple model of regulation, cybernetics. This word comes from the Greek
word kybernetes who is the man on a ship who takes the steering wheel. In other
words, steering of functions in complex systems are cybernetic processes. To begin
with we refer to a simplified mono-causal kind of linear function:

A water basin has an electric heater which is regulated by a thermostat. A target

temperature is defined, in this example 37 C (figure 3).
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 Master Thesis 2011

Figure 3 - Water basin model (Greten, 2010)

Before work in the morning, the incubator will have reached room temperature.
In phase 1 we may switch on the system. The thermostat will switch on the electric
heater as the actual temperature is lower than the target temperature. This will take
some time and temperature will rise to 37 C (Phase 0).

In stage I, when the target temperature has been reached, the thermostat will
cut off electricity to the heater. This means that the heater won`t furthermore gain more
energy. Nevertheless the heater is still warmer than the water. If we switch off the heat,
we cannot yet touch the plate. This amount of heat is called afterheat, in a technical
sense, and it causes a peak of temperature.

In stage II this excess afterheat is gradually used up, so the water cools down
back to the target value. After cooling down to 37 , the thermostat will switch on the
heater again.

During stage III it is switched on. Nevertheless, it takes some time until the
heater is hot again. This again is comparable to our electric stove. Switching on the
heater means that we can still touch the plate until it is hot. This phenomenon is
technically called latency.

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 Master Thesis 2011

In stage IV after some time, the heater will be warmer than the water and the
temperature and energy content of the basin will rise. This procedure happens now in a
repetitive manner. An endless chain of up and down movements will be taking place in
such a heated regulated system.

At first sight this is astounding, as it means that such a regulated system does
not hold the target value as we might expect. It is either too hot or too cold. Likewise,
afterheat causes the peak in temperature and latency causes the low. In a simplified
description this resembles a sinus wave.

We have some historical hints pointing to the fact that classical Chinese
regarded these cyclic processes actually as cyclic, as a circle. From a nowadays
standpoint this is only a rough assumption as the actual course of temperature is not
exactly a sinus wave. Nevertheless, for the simplicity and for a better access to this
model we name this the sinus curve of regulation.

Looking at a pipe organ player we see that the hand always moves in a cyclic
manner around the axis of the pipe organ. Looking from a perpendicular perspective,
this is an up and down movement in the middle of which the axis is situated. Likewise,
a standing pipe-organ player has an up and down movement (yang and yin movement)
of his hand. However, when he moves forward with his instrument, the movement of
his hand describes approximately a sinus wave. Therefore, a sinus wave is also called
a circular function.

Figure 4 - Movements of the hand of a pipe organ player seen from the side (left),
from the front (middle) and when walking (right) (Greten, 2010)

A sinus wave is a circular movement which we regard from another projective

standpoint. Looking from the different angle therefore changes the circular movement
into a sinus wave movement.

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 Master Thesis 2011

When the hand is up, it will then move down because the axis turns it down. The
axis in our regulatory example is the target value. We may symbolize this by a dot on
the target value line, the axis (Earth 1). When the hand is down, it will then move up.
This change of direction is mediated by the axis again. This upward power can be
symbolized by another dot on the target value line (Earth 3).

Referring to the classical circle of yin/yang descriptions of a circular movement, we

can insert in our regulatory model the phases Wood, Fire, Metal and Water as quarter
sections of the circular movement. Actually this symbol is a nice description for the fact
that the target value (here called Earth), the centre of the movement, exerts a down-
regulation in the first half of the movement and an up-regulation in the second half of it.

Chinese culture tends to put technical terms into emblems. In fact, all Chinese
language is expressed by emblems and classical characters. If we follow this tendency
on a mathematical level, we could express the mathematical content, not the
philosophical content, of this consideration by a circle that we draw around our
technical term. What comes out is the so-called monad or in Chinese terms the fou qi
sign or the tai ji sign.

Figure 5 - Phases (Greten, 2010)

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 Master Thesis 2011

This sign is also referred to as the yin/yang symbol. Its mathematical meaning is
that yin and yang form a binary language of numbers that are able to describe circular
functions such as in regulation. We therefore consider this sign to be a symbol for the
scientific approach to natural processes rather than a mystical, philosophical approach
which is common in the public presentation of Chinese Medicine nowadays.

1.2.1.4 Why is this good for medicine?

On the ordinate we may not only plot the temperature but other values as well,
for example the overall vegetative activity of man. High activity would then be yang or
repletion, low activity would be yin or depletion. In other words, one of the possible
interpretations of yin and yang are:

- yang above target value and

- yin below target value.

In the yang phases sympathetic functions dominate more than in the yin phases.
In the yin phases, however, the parasympathetic (vagal) activity is relatively more
present. Of course, the vegetative system consists of more than sympathetic and
parasympathetic activities.

In the first major description of the vegetative system leading to the Nobel Prize in
1927, the original description is to categorize vegetative functions and its nervous
system into sympathetic, parasympathetic and intestinal nerve fibres. For instance, the
enteric nerve system is less active while we are highly agitated, as defecation would be
dysfunctional in stress and fight situations. On the other hand, in the phases of down-
regulation like in the phase of Fire and even in lack of energy (Metal), the enteric nerve
system is more active to restore energy levels. We can also insert in the picture muscle
tonus and motion patterns by hypertonic, hyperdynamic, hypotonic and hypodynamic
functional patterns or the RAAS (renin angiotensin aldosterone system) which is more
active in the yang phases above the target value and less active in the yin phases
below the target value.

Like this one could design a whole concept of a transmitter concert according to
western medicine. Likewise, the concert of transmitters and the neuronal pathways

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 Master Thesis 2011

involved would define a complex pattern of physical functions which is indicated

schematically and in a reduced form in the lower part of the figure 6. This can be called
the western physiological description of such a vegetative sinus curve.

In the upper part of the figure 6, functional figurines symbolise the clinical
appearance of these mechanisms in terms of visible signs. For instance, the
coppersmith in Wood has a lot of extensor muscles being active, and blood pressure
presumably is higher than in the Lady reading the bible in the phase of Metal. The
patterns named above exactly correspond to the clinical description of Chinese
Medicine. In other words, the description by groups of clinical signs in the upper part of
the figure describes the same functions that western medicine describes as a
transmitter and neuronal concert of the vegetative system.

Figure 6 - Phases (Greten, 2010)

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One could therefore say: the upper part contains the Chinese way of
description, the lower part contains the western description. Of course this is a
mathematical function irrespective of whether we express this by yin/yang lines or by
Wood, Fire, Metal and Water. The Chinese description would be that the left part
(Wood and Fire) gets the category of yang, whereas the right side (Metal and Water) is
yin. By trigrams we can then create the numbers 1 4 and that was later replaced by
Wood, Fire, Metal and Water, the so-called phases. The signs and symptoms which
indicate the phases are referred to as organ patterns or orbs (circle of diagnostically
relevant signs). Four of these are especially essential to understand the unity of signs
and emotional expression.

1.2.2 According to TCM and to the Heidelberg model emotions and anxiety are
associated with vegetative functional changes called organ patterns or orbs
As we have already referred to, there are four phases: Wood, Fire, Metal and
Water. There is an additional phase called earth which is responsible for turning the
axis, which is neglectable in this context for the moment. All these correspond to
functional patterns named organ patterns or orbs, which will be briefly described here.

According to the Heidelberg model wood is described as the phase of creating

potential (energy). This means that if a person is on the phase wood, he is full of
energy and he will release this potential quickly if it is necessary. This person may
seem like an explosive which blows up the energy and a social conflict. This phase
could be expressed by hepatic or felleal orb. A person expressing hepatic orb will have
hypertonic muscles, shouting voice, opening eyes as it is seen in the Figure 7. The
emotion related to this orb is ira (anger).

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 Master Thesis 2011

Figure 7 - Hepatic orb, the emotional expression is referred to as ira (Greten, 2010) Chinese
Medicine understands this state as a consequence of regulation of vegetative functions.

Fire is described as the phase of transformation of potential into function.

Creating such function from an elevated potential means that a hyperfunctional state
can be observed in this phase. This phase could be frequently expressed by cardiac or
pericardiac orb. A person expressing signs of cardiac orb will be hyperdynamic, will
present laughing voice, brilliant eyes and he will speak moving the hands, as we can
see in Figure 8. The emotion related to this orb is voluptas. Pericardiac people are full
of unrest and they are characterized by never having time. Pericardiac people are
commonly cardiac with a weak yin, which have been humiliated so far that their anxiety
is high.

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 Master Thesis 2011

Figure 8 - Cardiac orb, the emotional expression is referred to as voluptas (Greten, 2010)
Chinese Medicine understands this state as a consequence of regulation of vegetative
functions.

Metal starts when the polarity changes. This means that metal is described as
the phase of relaxation. This phase is responsible for the rhythmical functions of the
body, like the motion of breathing. This is the way the functions of metal are mostly
expressed by the pulmonary orb. A person in this phase will be hypotonic, will present
a wailing voice, hanging shoulders and lack of energy as we can see in Figure 9. The
emotional state related to this orb is called maeror (agony, grief).

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 Master Thesis 2011

Figure 9 Pulmonary orb, the emotional expression is referred to as maeror (Greten, 2010)
Chinese Medicine understands this state as a consequence of regulation of vegetative
functions.

Water is the phase in which the energetic potential is regenerated.

Regeneration of energy during the sleep and reproductive functions are expressions of
the phase water. This phase is related to renal orb. A person expressing renal orb
signs is hypodynamic, with unemotional voice, weak legs and lumbar region as we can
see in Figure 10. The emotional state related to this orb is called timor (anxiety) that
leads to over-rationality.

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 Master Thesis 2011

Figure 10 Renal orb, the emotional expression is referred to as timor (Greten, 2010) Chinese
Medicine understands this state as a consequence of regulation of vegetative functions.

To explain anxiety we will focus on fire/water axis. As we have referred before

the renal personality pattern includes regenerative vegetative functions, so in this
phase there are a lack of energy and a lack of yin (cellular functional capacity). It is
supposed that this makes the renal person subconsciously vulnerable and leads to the
need of more emotional security. This may be called anxiety which is mostly hidden
under a rational mask. Anxiety may block and may paralyze the person in a moment of
challenge. Renal people tend to plan their lives and they may become nervous and
anxious when incalculable events happen. This anxiety that leads to over-rationality

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could be called timor, and as we have already referred, timor is the emotional state
related to the renal orb and constitution.

As we have said before pericardiacs are frequently cardiacs with a lack of yin
who have been humiliated so far that their anxiety is high. Renal types rationalize their
anxiety while pericardiacs act out anxiety by constant hyperactivity. Both may be
empirically stated for challenging situations like auditions, in which some individuals
seem to be paralysed and cold (renal pattern), whereas others are hectic and panic
(pericardiac pattern). To diminish anxiety it is necessary to work both on fire and water
patterns, and to keep people safe and secure.

1.3 Qigong effects in the language of TCM

According to Dorcas and Yung (2003), Qigong can be defined as an
indigenous Chinese holistic form of exercise that originated at least 5000 years ago.
More than 1000 forms of Qigong are practiced today in China (Li, Chen and Mo, 2002).
According to Li, Chen and Mo (2002), the original purpose of Qigong practice hasn`t
been used for treating diseases but for preventing them. Qigong doesn`t treat just the
symptom or the disease, but helps the person to restore what is called the Qi flow, in
western terms, their capacity to adapt functionally by their vegetative nervous system.
Although it is speculated that most Qigong forms bring health benefits, medical
Qigong is a small and specialized area of Qigong that has been specifically developed
for treatment and cure of diseases (Chen, Yeung, 2002).
Qigong consists primarily of meditation, physical movements and breathing
exercises. Qigong masters developed the skill of feeling the sensation of Qi and work
with it using their mind and intention (Sancier, 1996). According to Yu (1999) (in Tsang
et al, 2003) Qigong may have an effect comparable to antidepressants.

According to Gonalves (2010) Qigong works with the so-called 3 treasures of

Traditional Chinese Medicine: Qi, Shen and Jing. According to the Heidelberg model,
and as we have said before, Qi is the vegetative capacity to function of a tissue or
organ which may cause the sensation of pressure, tearing or flow. Shen is a functional
capacity to put order into mental associativity and emotions, thus creating mental
presence. The functional state of Shen is evaluated by the coherence of speech, the
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 Master Thesis 2011

gloss of eyes and fluent fine motor capacities (Greten, 2010). According to the same
model Jing is translated by the term of structive potential. Structive potential means the
possibility to create structure by cell populations. It refers to the general regeneration of
body structure as well as the build up of organs during embryology. Structive potential
also refers to the potential of the structure to exert function. This is comparable to the
basic repertoire of functions that the cells are offered in western medicine by the
nucleus of the cell (Greten, 2010). Using more common terms, Qi is the energy, Shen
is the mind and Jing is the body with its functional and regenerative capacities. As a
conclusion, Qigong works with functional capacities, with the body and with the mind.
Qigong is also believed to relax the body, to promote the flow of Qi, blood, oxygen and
nutrients to the cells of the body and to promote the removal of waste products from
cells (Sancier, 1996).

1.4 Measurable and hypothetic effects of Qigong

Chinese studies claim that Qigong, a traditional vegetative biofeedback therapy,
helps to relax mind, muscles, tendons and joints by exercises involving physical
movements, focused meditation, breathing and self massage. It is speculated that as
the injured tissues become more relaxed, vasoconstriction would decrease and blood
circulation increase. This phenomenon could promote the removal of metabolic waste
and increase delivery of pain killers such as endorphins (Sanciers, Hole, 2001).

In fact, practicing Qigong may favorably affect many functions of the body,
permitting the reduction of the dosage of drugs. Studies also suggest that Qigong
provides greater health benefits than the use of drug therapy alone in certain cases. As
an example, for hypertensive patients Qigong exercises combined with drug therapy
reduce the incidence of stroke, death and the dosage of drugs required for blood
pressure maintenance. In asthma patients the combined therapy has permitted the
reduction in drug dosage, duration of hospitalization and costs of therapy. It also
improved the immune and cardiovascular systems and increased the general condition
of patients (Sanciers, 1999).

There are a great number of cancer patients using TCM as an alternative

medicine to help treat cancer. A systematic review was done by Chen and Yeung
(2002) with more than 50 studies about Qigong therapy for cancer in China.
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Unfortunately, most of them can only be considered to be of anecdotal value, as they in

most of the cases do not meet western scientific standards. The authors concluded that
Qigong therapy may improve immune function, increase microcirculation and raise the
pain threshold. The studies on Qigong and its curative effect on cancer have
demonstrated consistent results for inhibitory effect on cancer growth and metastasis in
clinical observation. Patients who practice Qigong had more improvement or better
survival rate than patients who don`t.

1.4.1 Vegetative Physiological Effects

Machi (1994, in Sancier, 1999) demonstrated with thermography that Qigong
exercises can increase skin temperature, which implies greater blood circulation in
some areas of the body. Qigong also can affect brain waves, blood pressure and heart
rate (Machi, 1994, in Sancier, 1999). At the same time, Sanciers (1996, 1999)
speculate that an increase in blood circulation can help to explain the effect of Qigong
on many different functions of the body. Increased blood circulation enhances delivery
of oxygen and nutrients to the cells and increases the efficient removal of waste
products. These may help stressed tissue increase the efficiency of body functions
including immune response. Those studies suggest that Qigong exercises are
effective for balancing organs of the body.

1.4.2 Qigong and Stress (as measured by blood pressure, heart rate, urinary
catecholamines, cortisol level)
The following studies are quoted for an anecdotal documentation of qigong
related effects. Some of the studies were insufficient described in terms of
methodology, statistics, out come and controls. The results of these studies are
contradictory, the Chinese functional diagnosis not consider and the allocation of the
exercises to the clinical pictures generally remain unclear. However none of these
studies refer to the white ball exercises

Lee et al. (2003) have carried out a study to determine the effects of Qigong on
blood pressure, urinary catecholamines (indicators of stress) and lung function in
middle aged patients with essential hypertension. The examiners formed 2 groups
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 Master Thesis 2011

(control group and Qigong group) of 29 participants each one. The Qigong group did
30 minutes of shuxinping-xuegong per day during 10 weeks. Blood pressure, urinary
catecholamines, forced vital capacity and forced expiratory volume per sec were
measured before and after 10 weeks. The results show that after 10 weeks, the levels
of blood pressure were smaller in the Qigong group than in the control group as well as
the levels of catecholamines. At the same time the Qigong group improved the lung
function. The examiners concluded that Qigong can help to improve the lung function
and reduce blood pressure and stress in middle aged patients. These results suggest
that Qigong has relaxation effects and stabilizes the sympathetic nervous system in
patients with essential hypertension.

Another study carried out by Skoglund and Jansson (2006) in England, aimed
to investigate the effects of Qigong on stress among computer operators. 20 women
were divided into 2 groups. The Qigong group (n=10) had daily sessions of 30 minutes,
from Monday to Friday, during 5 weeks and the control group (n=10) continued with
their usual daily work. Heart rate, blood pressure and finger temperature were
measured at the beginning and at the end of the working day as well as the perception
of stress (Borg`s 0-20 grading scale). 24 hours urine samples were collected in the first
and in the last weeks to measure catecholamines. The results showed that Qigong
reduces heart rate, finger temperature and noradrenaline in urine. Although there were
no effects on blood pressure and on the level of perceived stress, symptoms such as
low back pain were significantly reduced. These results show that Qigong may have an
effect of the activity of the sympathetic nervous system and may reduce stress in
computer operators.

In Hong Kong, Jones (2001) carried out a study to investigate the changes in
cytokine production in healthy subjects practicing Qigong. Cytokines are glycoproteins
which are involved in immune response as pro-inflammatory and anti-inflammatory
regulators. 19 participants were asked to practice two hours of Qigong (Guolin Qigong)
per day during 14 weeks. Blood pressure, pulse rate, blood cortisol level and
production of cytokines were measured before training and after 3, 7 and 14 weeks.
The results showed no significant changes in systolic or diastolic blood pressure but
the pulse rate decreased. This preliminary study indicates that blood levels of cortisol
may be lowered by short-term practice of Qigong and that there are concomitant

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changes in the number of cytokines. These results show that Qigong improves the
stress-coping skills of the participants, however further studies are needed.

Maldonado et al. (2005) have carried out a study, in Spain, based on

examination of Qigong effects in the quantity of hormones, anxiety, blood pressure and
subjective quality of sleep in university students. 25 students were divided into control
group (n=13) and Qigong group (n=12). The Qigong group completed a program of 30
minutes of Qigong lessons 5 times a week, and self-practice during the weekends, for
1 month. The evaluation of blood cortisol, ACTH, TSH and PTH, blood pressure,
anxiety (Escala de ansiedad de Hamilton and Inventario de ansiedad de Beck) and
subjective quality of sleep (Cuestionario de calidad subjetiva de Pittsburg) took place at
the begging and at the end of the study. Results showed no significant differences
between the 2 groups in blood pressure and subjective quality of sleep. However the
Qigong group had lower cortisol, ACTH and anxiety levels than the control group,
which suggests that the regular practice of Qigong may inhibit the hypothalamic-
pituitary-adrenal axis.

Lee et al.1 (2004) have carried out a study to investigate the effects of Qigong
on anxiety and plasma concentrations of cortisol, ACTH and aldosterone. 32 men were
divided into 2 equal groups. The Qigong group completed a program of Qigong
exercises daily, during 4 weeks. The exercises were directed by a Qigong master
during 60 minutes per session. The control group also performed the movements
without gathering or moving Qi. Measurements were done at the beginning and at the
end of the program using blood samples. The participants also answered to the
Spielber`s state-trait anxiety scale, which includes 20 items to measure the acute level
of anxiety. Results showed that anxiety decreased 26% in the Qigong group and just
9% in the control group. These results suggest that the movements used in Qigong
could positively affect anxiety states, however this effect is much smaller than that
associated with Qi training. The results also showed that blood concentrations of
ACTH, cortisol and aldosterone were significantly smaller in the Qigong group than in
the control group. In conclusion, those results suggest that Qigong had a significant
effect on hypothalamic-pituitary axis, which might reflect stabilization of anxiety level.

Lee et al.2 (2004) have done a study aimed to investigate the effectiveness of
Qigong on blood pressure and several blood lipids such as HDL, total cholesterol,

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apolipoprotein A1 and triglycerides in hypertensive patients. 36 participants were

divided into a Qigong group (n=17) and a waiting-list control group (n=19). The Qigong
group completed a program of shuxinpingxuegong during 8 weeks, 30 minutes twice
week. Measurements were done at the beginning and at the end of the study by blood
sampling and auscultatory method. Results showed a significant decrease in blood
pressure, HDL, total cholesterol and apolipoprotein A1 in the Qigong group (=0,001).
The authors concluded that Qigong could reduce blood pressure and change lipid
metabolism to benefit health. Furthermore it can be hypothesized that Qigong has
antihypertensive effects and reduces blood pressure via modulation of lipid levels.

These studies suggest that Qigong exercises, over even a short period of time,
may be able to significantly reduce symptoms of stress by diminishing blood pressure,
heart rate, cortisol levels and other stress related parameters.

1.4.3 Qigong and Mood

The studies quoted here, as mentioned in the introduction, may suffer from
some methodological shortcomings, but are quoted here to underline these difficulties
and the necessity to develop better study designs.

Tsang and colleagues (2003) studied, in China, the influence of Qigong (eight
brocades section adapted) in the elderly diagnosed with depression. For that, 50
participants were divided into two groups: the experimental group, with a mean age of
72.9 (SD = 9.5) years old, and the control group with a mean of 76.3 (SD = 8.4) years
old. Both groups received basic rehabilitation activities for 12 weeks. The experimental
group also received one hour practice of Qigong, twice a week, during 12 weeks. The
experimental group was also advised to practice Qigong exercises daily for at least half
an hour. The results were measured with different scales and questionnaires, which
measure the degree of depression (geriatric depression scale), the state of physical,
psychological and social (Perceived benefit questionnaire), quality of life (Hong Kong
Chinese World Health Organization version quality of life) and self-concept (self-
concept scale). The researchers concluded that Qigong improves physical health,
psychological and social development of elderly people, reducing the degree of
depression and increasing their quality of life. However, the results were not
statistically significant.
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 Master Thesis 2011

Chow and Tsang (2007) have done a literature research to study the effects of
Qigong on people with anxiety disorders. The investigators concluded that Qigong
could be considered a valid alternative to treat anxiety disorders. Pharmacological
treatment could have side effects such as nausea, vomits and addiction. Qigong can
be implemented at home or outdoor at any time during the day, it is convenient,
inexpensive and easy to do.

Oh and his colleagues (2010) carried out a study, in Australia, aimed to

evaluate the use of medical Qigong compared with usual care to improve quality of life
of cancer patients. They recruited 162 patients divided in 2 groups: the control group
(n=83) and the intervention group (n=79). The intervention group received usual
medical care and attended a Qigong program during 10 weeks, 90 minutes per week.
They also were invited to practice Qigong at home daily for at least 30 minutes. The
measurements were done at the beginning and at the end of the study. Quality of life,
fatigue and mood status were measured by Functional Assessment of Cancer Therapy,
General and Functional Assessment of Cancer Therapy and Profile of Mood State. The
inflammatory marker serum C- reactive protein was monitored too. The results showed
that Qigong significantly improved quality of life, fatigue, mood disturbances and
inflammation. The authors concluded that medical Qigong can improve quality of life,
mood status and reduce specific side-effects of treatment in cancer patients.

Li, Chen and Mo (2002), carried out a study in China to explore the
effectiveness of Qigong therapy on detoxification of heroin addicts compared to
medical and nonmedical treatment. Participants were randomly assigned to one of
three groups, 34 were included in the Qigong group, 26 in the medication group and 26
in the no treatment control group. The first group practiced 2 to 2,5 hours of gigong
(Pan Gu Qigong) daily during 10 days. The medication group received the
detoxification drug during 10 days using gradual reduction method. The control group
received only basic care and medications to treat several symptoms like pain, diarrhea
and sleep disorders. The examiners used the urine morphine test, electrocardiogram,
withdrawal syndrome evaluation scale and Hamilton anxiety scale before and during
the 10 days of intervention. The investigators reported that the reduction of withdrawal
symptoms were faster in the Qigong group than in the other groups. Both the Qigong
and the medication group had lower anxiety scores than the control group, but the
scores of anxiety were lower in the Qigong group than in the medication group. By day
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 Master Thesis 2011

5 of treatment, all participants of Qigong group had negative urine tests compared to
day 9 for the medication group and day 11 for control group. These results suggest that
Qigong may be an effective alternative for heroin detoxification without side effects.

Those studies suggest that Qigong has a positive effect on anxiety disorders
and depression. It is also suggested that Qigong can improve quality of life, mood
status and reduce specific side-effects of treatment in cancer patients. Qigong may
also be a helpful complement for heroin detoxification.

1.4.4 Effects of Qigong on schoolchildren

There are also some studies about the effects of Qigong on schoolchildren.

Witt et al. (2005) did a pilot study in Germany, to evaluate the effects of Qigong
lessons on schoolchildren in terms of their achievements at school, social behavior and
general health. The sample consisted of 90 children aged between 7 and 13 years old,
were divided into two homogeneous groups: control group and experimental
group. The experimental group received Qigong lessons (xiang-gong) over 6 months,
twice a week, during 15 (level 1) or 25 minutes (level 2). To measure the results
teachers, parents and children answered standardized questionnaires at the beginning
and at the end of the study. The 5 teachers also answered semi-structured in-depth
interviews. After 6 months, the Qigong group showed significantly better results in the
teacher questionnaire but no effects were found in the parent questionnaire. The result
showed that during the study, the number of complains remained similar, whereas the
severity of the medical complains decreased in both groups. However, the teacher
questionnaire reported that Qigong influences grades and social behavior of the
children positively. Evaluating these data from our point of view one mait speculate that
the teachers expectations maight have been diferent from the parents more neutral
expectations which may question the methodological approach.

However, qualitative analyses and so forth indicated a relevant decrease of

individual complains for some children in the Qigong group (warmer hands and feet,
fewer allergy problems). Teachers also reported that Qigong exercises had calming
and relaxing effects on the children. The authors concluded that Qigong helps to

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 Master Thesis 2011

improve social behavior and grades but further studies are needed to generalize these
results.

Another pilot study carried out in Germany by Witt et al. (2007) aimed to study
the effects of xiang-gong in the health of schoolchildren with 10-11 and 16-17 years
old. For that, 140 children from 4 different schools received Qigong lessons, twice a
week, during 15 (level 1) or 25 minutes (level 2) over 6 months. At the end of the study
semi-structured in-depth interviews were conducted with the participating teachers. The
reported effects were of a social nature as well as improvement in vitality, medical and
psychological health. Teachers also reported that students became calmer, more
energized, "harmonize" and less aggressive after exercise. The only negative effect
was the existence of nightmares during an early stage. The investigators concluded
that Qigong helps to enhance vitality and community strength and also social,
psychological and in some cases medical improvement.

These two studies suggest that Qigong could be integrated into regular school
classes and it could help to improve the social behavior, grades and general health.

Those studies also suggest that Qigong has good effects on many functions of
the body including the regulation of blood pressure, heart rate, urinary catecholamines
and cortisol level. Those references also suggest that depression and anxiety disorders
could benefit from Qigong exercises. In the same way, studies suggest that Qigong can
help to increase quality of life in cancer patients and to reduce drug dosage in health
condition such as asthma and hypertension. Despite those conclusions, some of those
studies have small samples and they aren`t random. They also use different types and
different Qigong exercises, during different periods of time and frequency.

Western medicine classifies the different pathologies according to their similar

symptoms and causes. In TCM it is needed an individual approach to each case and
to each patient. For example according to TCM, hypertension could be caused by
different conditions and the treatment is completely different according to the cause.
This fact is difficult to coordinate with a rigorous investigation. According to the
Heidelberg model, standardized TCM treatments aren`t so efficient as individualized
treatments. Doing investigation it is needed to standardize protocols. Those
standardized protocols don`t present the same effects as individualized treatments and
this fact must be referred.
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 Master Thesis 2011

2. Study design

2.1 Investigation question and aim of the study

Investigation question:

Do Qigong exercises influence the anxiety levels and the physiological stress functions
of 10 - 12 year old music school children playing the transverse flute before auditions
and concerts?

Are those effects possible to be further objectified by physical and psychological

measures?

Aim of the study: This study aims to evaluate if and how Qigong related effects may be
further objectified by physical measurable parameters and psychological scores. For
this propose we examined 10 12 year old music school children playing the
transverse flute before auditions.

2.2 Objectives
To evaluate if and how Qigong related effects may be objectified by the level of
salivary cortisol;

To evaluate if and how Qigong related effects may be objectified by

psychological scores using EADS-C;

To evaluate if and how Qigong related effects may be objectified by the

superficial muscle tension (of trapezius muscle);

To evaluate if and how Qigong related effects may be objectified by heart rate
and blood pressure immediately before the audition;

To evaluate if and how Qigong related effects may be objectified by reaction

time;

To study the influence of Qigong exercises on anxiety and physiological stress

functions of 10 to 12 year old music school children playing the flute.
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 Master Thesis 2011

3. Methods

Definition of the study: This is a prospective controlled interventional study with

waiting list design.

3.1 Recruitment
Academia de Msica de Paos de Brando, Academia de Msica e Artes de
Rio Meo, Academia de Msica de Santa Maria da Feira and Conservatrio de Msica
de Fornos were contacted to integrate the study. Those academies were chosen
because they are located near Porto and they are convenient to the investigators. Just
the first two agreed to participate. The first contact was done with the directors of the
respective academies. After pedagogical council approval, parents and children were
contacted by the investigators and by the respective academy to integrate the study.
Parents and children who fulfilled the inclusion criteria, were invited to a meeting and
they were informed about the study.

After having been signed the informed consent form (annex 4) by the
participants and their legal representatives, the children were distributed to either the
control group or the study group, according to their interest and schedule to integrate
Qigong classes. Because of those facts we can`t consider this a random sample.

3.1.1 Inclusion criteria

- Music school children of 10 - 12 years of age playing the transverse flute;

- Capability to follow the Qigong instructions in terms of Portuguese language skills;

- Written consent.

3.1.2 Exclusion criteria

- Major psychological problems;

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 Master Thesis 2011

- Previous experience with Qigong.

3.2 Intervention

3.2.1 Control group

In the control group 8 children were included and they didn`t receive any
intervention (waiting list design). Due to the low number of children available we failed
to randomize the allocation to the groups. The children were allocated to the groups by
pragmatic arguments, for example whether they were available at the qigong practice
hours.

3.2.2 Qigong group

In the Qigong group 8 children were included and they received specific Qigong
lessons of the so-called white ball Qigong over 7 weeks, twice a week, for 30
minutes. They also were instructed to do the exercises at home daily.

The intervention was done from 18th March until 6th May.

3.2.2.1 Qigong exercises and their explanation

According to TCM (Greten, 2009), an emotion is an inner movement (Latin

emovere = to move out of something) of the so-called centered inner posture, a
balanced functional vegetative state. This state is referred to as the balanced or Earth-
position in which a total balance of emotionality is observed. Inner motions, such as
symbolized by the phases lead to so called organ pattern or orbs, a part of which is an
emotional shift towards the so called basic emotions in TCM. They are also known as
inner agents and may lead to

maeror (eg. inner pain)

voluptas (eg. over-excitement)

ira (eg. aggression) and

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 Master Thesis 2011

timor (e.g. hidden or open anxiety)

According to the same author, TCM holds that emotions are originated in the
body so, by balancing our body functions, we automatically balance and diminish
pathologic emotional patterns within our vegetative nervous system.

This thesis explains the obvious natural feedback leading to emotional self-
healing by certain Qigong exercises. In brief, Qigong allows the practitioner, by
imagination, motion, breath-control, to be more psychosomatically balanced. This
process of subconscious self-regulation is programmed and learned. By the time, this
balanced state may be neurologically conditioned, and remains in our vegetative
nervous system, becomes part of our inner nature. By the time we will become more
stable with challenge, resulting in a better quality of life.

To do Qigong exercises it is needed that the child assumes the following posture:

- The back must be straight;

- The knees must be put in a way that the child can feel R1 (renal 1: fons
scatens): a little bit bent with no rotation;

- The pelvis must be in retroversion and without the lumbar curve.

a) Man between heaven and earth

With this exercise the child must connect to the ground because he/she will
connect to the biggest yin that exists. This concept of TCM, refers to the 4th guiding
criteria which distinguishes between a naturally labile state (yin deficiency) and other
causes of deregulation. The picture also suggests that the earth gives strength and
security. Connecting to the ground, the child will activate the renal orb and therefore
he/she will be free from anxiety. At the same time all regulation becomes constant
because yin is endlessly big. To connect to the ground the child must feel R1 and
transfer his/her weight to the earth (Greten, 2009).

The next step is to connect to the sky. Connecting to the sky, the child will
connect the renal and the cardiac axis and he/she will connect to his/her intuitive
intelligence and will be able to have an intuitive access to his/her inner inborn way of
life. At the same time the child will be connected to heavenly guidance. To connect to

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 Master Thesis 2011

the sky the child must feel Rg 20 (conventus omnium yang) and feel the line which
crosses all the body since R1, passing through the dantian, until Rg 20 (Greten, 2009).

After the connection between heaven and earth is completed, boys must
breathe out 7 times and girls must breathe out 8 times.

b) The white ball

The white ball is an important exercise that connects the Qi flow of the 2 hands,
activating pericardiac flow (which is the hepatic orb of upper caloric) by Pc8 (medium
palmae). Accumulated stress in upper caloric flows off and pathological repletion is
relieved. At the same time, Pc 8 is considered to represent all orbs of the body as well
as each finger is also associated to the phases. Connecting the Qi of the two hands
promotes a big balancing and clearing effect. To connect the Qi of the 2 hands the
child must close the eyes, hold the arms in front of the dantian as if he/she is holding a
ball and adjust the distance between the hands (Greten, 2009).

After connecting the two hands, it is necessary to purify the Qi between the
hands. The image of flowing out of the body is an old concept of Chinese medicine. By
visualizing a purifying effect, the nervous system is cleaned up, pain free and
emotionally positive. To purify the Qi of the white ball, the child must imagine that all
bad things go out to the nature, and the ball becomes more and more white and
shining. In the end the child must breathe out 7 times (for boys) and 8 times (for girls)
(Greten, 2009).

c) Feeding the kidney region

Feeding the kidney region is important because it strengthens the substance of

the child. To do that the child must put his/her hands above the navel (at the level of
the dantian). First, girls must put the right hand and then the left hand, boys must do
the contrary. Pc 8 of both hands must be connected with the dantian. After that, the
child must put his/her hands above the kidney region and feel the Qi flow (Greten,
2009).

d) Closing the girdle conduit

It is very important that, before finishing the exercises, the child closes the girdle
to close the surface and be protected. To do that, the child must move the hands until
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 Master Thesis 2011

the dantian, connecting again the point Pc 8 by placing one hand over another and
connecting these two points with the dantian (Greten, 2009).

e) Thanking the principal

Before finishing it is necessary to find the appropriate relation with the world. To
do this the child must bend his/her wrists perpendicularly, rotate downward and bend
the neck which may follow the movement of the hands (Greten, 2009).

3.3 Measurements
Subjective anxiety perception: Escalas de ansiedade, depresso e stresse de
21 itens de Lovibond e Lovibond;

Heart rate and blood pressure: M6 Comfort (Omron), automatic blood pressure
monitor;

Basal muscular tension of trapezius muscle: Electrical Potential measurements

by Superficial Electromyography using MP36 - BIOPAC Systems, inc;

Time reaction: Stimulus response situation by MP36 BIOPAC Systems, inc;

Levels of cortisol in the saliva by the Salivette (Sarstedt).

Ideally all students must play in an audition on 17th March and on 6th May, and
measurements must be taken during those days. All participants of the Qigong group
follow the expected program but, unfortunately, 5 students of the control group can`t be
present in the last audition. For this reason we did another audition on 19th May. The
conditions of the first and of the second audition were the same since the students
played in a neutral place. The third audition was in Academia de Msica de Paos de
Brando, a familiar place for all students. Another different aspect was the amount of
public that attended to the audition since the first and the second auditions had much
more public than the third audition. We were conscious that those facts could influence
the results but this was the only solution found to solve the problem.

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 Master Thesis 2011

The saliva cortisol measurement ideally took place in the morning of the audition`s
day, before breakfast. Unfortunately in the first audition, 3 students of the control group
forgot to do the measurement during the morning. To solve this problem they did the
measurement during the afternoon, at the same hour in the first and in the second
auditions. In the second audition two of the Qigong students forgot to do the
measurement. To solve this problem again we canceled the first measurement and for
this reason we just have six measures of saliva cortisol in the Qigong group and eight
in the control group.

The scores were done during the audition`s day by all students with no
exceptions. Heart rate and blood pressure were measured by a nurse immediately
before the student goes to stage. Reaction time and basal muscular tension of
trapezius muscle were measured 2 hours before the concert.

Thermography allows the measurement of capillary flow of the hands before

and after training sequence. Measurements were done by Luis Matos at the beginning
and at the end of the study (data shown on the master thesis of Luis Matos).

3.3.1 Escalas de depresso, ansiedade e stress para crianas (21 itens)

The Escala de depresso, ansiedade e stress (EDAS) is the Portuguese version of
Depression anxiety and stress scale (DASS) of Lovibond and Lovibond (1995).
Theoretically the DASS corresponds with the tripartite model of anxiety and depression
1,2
of Watson et al. (1991). This model suggests that anxiety and depression share
some features but have some different signs too. Depression is characterized by low
positive affect and anhedonia, while anxiety is characterized by symptoms of arousal.
At the same time depression and anxiety have in common a non-specific factor of
general distress. The properties of DASS were evaluated by Lovibond and Lovibond.
They used a normal sample of 717 participants who were also administered the Beck
Depression Inventory and the Beck Anxiety Inventory. The DASS showed satisfactory
psychometric proprieties: 0.81 correlation to Beck Anxiety Inventory and 0.74 to Beck
Depression Inventory (Lovibond, Lovibond, 1995).

Ribeiro, Honrado and Leal (2004) adapted the DASS to Portuguese population
and gave it the name of Escala de ansiedade, depresso e stress de 21 itens. They

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 Master Thesis 2011

also correlate the short (21 items) and the long (42 items) version of the scale. The
results showed that the Portuguese version of DASS has similar proprieties as the
original version of the same scale, and could be used with good internal consistence of
0.85 for depression, 0.74 for anxiety and 0.81 for stress in Portuguese population. They
also concluded that there are a great correlation between the long and the short
version of the scale (96% for depression, 90% for anxiety and 89% for stress).

Leal et al., in 2009, adapted the EADS to children and called it Escala de
depresso, ansiedade e stresse para crianas (EADS-C). They applied the scale to
361 children with ages between 8 and 15 years old. The results showed that the
EADS-C could be applied to this population with internal consistence of 0.78 for
depression, 0.75 for anxiety and 0.74 for stress.

The EADS-C is conceptually equal to EADS but the vocabulary was revised to
be easily understood by children. The final version of EADS-C is composed by 3 sub-
scales of 7 items each one that evaluate depression, anxiety and stress. The
depression scale includes items that measure symptoms typically associated with
dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest or
involvement, anhedonia, and inertia. The anxiety scale includes items that are primarily
related to symptoms of physical arousal, skeletal muscle effects, situational anxiety,
and subjective experience of anxious affect. Stress scale includes items that measure
difficulty in relaxing, nervous arousal, being easily upset or agitated, irritable or over
reactive, and impatient (Ribeiro, Honrado and Leal, 2004; Leal et al., 2009). For each
item the children may say if he/she passed through the respective symptom in the last
week. The EADS-C uses a scale of 4 different frequency or gravity degrees: 0 means I
don`t have, 1 means I have sometimes, 2 means I have frequently and 3 means I
have most of the time (Leal et al., 2009).

Children answered the questions of the scale at the beginning and at the end of
the study, before the audition, on audition`s day, with parents help. The EADS-C is
complete in annex 3.

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 Master Thesis 2011

3.3.2 Heart rate and blood pressure

According to Choi and Osuna (2009), stress is a term that describes body
reactions to a range of perceived physical or psychological threats. If it becomes
chronic, stress can cause serious health consequences and it is a risk factor for heart
diseases. According to the same authors, heart rate, blood pressure, muscular tension
and respiration are physiological indicators of stress. Lundberg et al. (1994) also affirm
that heart rate and blood pressure increase with stressful situations and therefore they
are good indicators of stress and anxiety states.

The autonomic nervous system (ANS) belongs to the peripheral nervous

system and one of its functions is the maintenance of the body under stable conditions.
The ANS has two divisions: the sympathetic nervous system (SNS) and the
parasympathetic nervous system (PNS). The SNS prepares the body to act in cases of
potential threats and the PNS does the opposite and brings the body back to a rest
state. Both SNS and PNS innervate the sinoatrial node, the primary pacemaker of the
heart. The SNS activation increases heart rate and the PNS activation decreases it.
This physiological explanation allows the assumption that heart rate and blood
pressure are good indicators of stress (Choi and Osuna, 2009).

The measurements were done immediately before the child goes into the stage,
by a nurse, at the beginning and at the end of the study, using M6 Comfort (Omron),
automatic blood pressure monitor. The child was resting during at least 15 minutes, in
a sitting position, with both feet on the floor, and it wasn`t allowed to talk during the
measurement. The arm is a little bit bent and the brace was located above the elbow,
bellow the humeral artery.

Blood pressure values will be presented according to the formula of blood

pressure mean (Ribeiro, Garcia, Fiori, 2007):

Systolic BP + (Diastolic BP x 2)
3

3.3.3 Surface Electromyography (SEMG)

Electromyography measures the electrical activity of skeletal muscles and it is a
direct representation of the outflow of motoneurons in the spinal cord to the muscle as
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 Master Thesis 2011

a result of voluntary or reflex activation. Electromiographyc data could be taken using

surface or intramuscular electromyography. SEMG recordings provide a safe, easy and
noninvasive method (it isn`t necessary to penetrate the skin) that allows objective
quantification of the energy of the muscle. Active motor units are registered from two
active electrodes over the muscle. However, SEMG is usually more susceptible to
artifacts than intramuscular electromyography (IEMG). SEMG records may contain
electrical activity coming from other muscles (Trker, 1993).

Acoording to Trker (1993) to make useful recordings with SEMG it is

necessary to use superficial electrodes from large superficial muscles and take
appropriate precautions. The precautions include the use of active surface electrodes
(Soderberg, 1984) choose a bipolar recording technique (Soderberg 1992), ground the
subject (Gans, 1986) and the use of very short leads (Soderberg, 1984). Active surface
electrodes have high input resistance and therefore they aren`t sensitive to changes in
the electrical resistance of the skin. They amplify the signal several times before
connecting to the next amplifier and therefore minimize movement-related artifacts and
resistance-related changes in electromyographyc signs. Ground the subject by using a
ground electrode is used to minimize or eliminate the noise from electromyographyc
records. The length of the leads connecting the recording electrodes to the amplifiers
should be kept as short as possible to minimize the amount of electrical noise being
picked up from the power sources around the subject. In another way, intramuscular
electrodes must be preferred for recording the activity from small peripheral muscles or
muscles located deep within the body.

In this investigation we measured the basal muscular activity of trapezius

muscle, according to Hansson et al. (2000) as this is a superficial muscle, it is
accessible for SEMG. According to Lundberg et al. (1994), the psychological stress
increases muscular tension of the trapezius muscle measured by EMG. The authors
also affirm that the results are consistent with the assumption that psychological stress
plays a role in musculoskeletal disorders by increasing muscular tension. In the same
way, Krantz, Forsman and Lundberg (2004) also affirm that psychological and physical
stress increases the muscular tension of the trapezius muscle, measured by SEMG, as
well as the incidence of musculoskeletal disorders. They also say that there is an
association between sympathetic arousal and muscular activity.

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 Master Thesis 2011

Borini et al. (2010) have carried out a study to evaluate the influence of non-
experimental anxiety on electromyographyc activity of masseter and temporal muscle.
The authors concluded that anxiety can influence electromyographic records even in
non-experimental situations. Conrad and Roth (2006) have done a study to investigate
the influence of relaxation techniques on anxiety disorders. According to their review,
anxiety increases the general muscular activity measured by SEMG.

According to these 4 studies, muscular activity measured by SEMG is a good

indicator of stress and anxiety. The measurement was taken approximately 2 hours
before the audition, at the beginning and at the end of the study using MP36 - BIOPAC
Systems, inc. For the measurement we used 2 active surface electrodes and 1
grounding electrode to ground the subject. The recording technique was the bipolar
recording technique and the leads were as short as possible.

3.3.4 Time reaction

Anxiety, as a negative emotion, is frequently accompanied by changes in
cognitive processing. Attention deficit is often seen when subjects have to deal with
threat or stressed situations (Fales et al., 2008).

According to Wilson, Smith and Holmes (2007) there are two theories that
explain the relationship between anxiety and performance: the conscious processing
hypothesis (Masters, 1992) and the processing efficiency theory (Esysenck and Calvo,
1992). The conscious processing hypothesis (Masters, 1992) suggests that stress
situations increase anxiety and self-consciousness about performing successfully. This
heightened self-consciousness causes a breakdown of automated movement units into
a more consciously controlled sequence of smaller separated units. This process slows
performance and creates opportunity for error at each transition between units. The
processing efficiency theory predicts that cognitive anxiety, in the form of worry,
reduces processing and storage capacity of working memory, reducing the resources
available for a given task. This theory also proposes that worry causes a diversion of
attention from tasks.

In this study, children were submitted to a relative simple task: they had to listen
3 sequences of 10 sounds each one and press a bottom immediately after listening to

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 Master Thesis 2011

the sound. The first and the second sequences were non rhythmical and measured the
time reaction and the attention level of the participants. The third sequence was
rhythmical and measured the learning capacity of the children. The expected results
would be the decreasing of the time reaction from the first to the third sequence. If
children presented a low attention level and a high stress state the expected results
would be a constant time, an irregular atypical time or even an increasing in the time
from the first to the fourth sequence.
The measures were done at the beginning and at the end of the study,
approximately 2 hours before the audition, using the MP36 BIOPAC Systems, inc.

3.3.5 Levels of cortisol in the saliva

According Aardal and Holm (1995) the measurement of cortisol levels provides
a reliable tool for investigations of hypothalamus-pituitary-adrenal axis activity. The
cortisol levels could be measured in the serum, urine or in saliva. In serum, cortisol is
mainly protein-bound and only 5-10 % of total plasma cortisol isn`t bound to proteins.
This free plasma cortisol diffuses rapidly into saliva. In urine cortisol exists only in free
form and the values dont always correctly mirror the free cortisol concentration in
serum (Kiess et al., 1995, Aardal and Holm, 1995). There are some advantages of
collecting saliva samples instead of serum samples. Collecting saliva is a simple
sampling procedure and thereby the avoidance of stress-induced rise in cortisol
concentration. In the same way the sample can be easily taken at home and the
stability of cortisol in saliva allows the transportation at room temperature. According to
Aardal and Holm (1995) saliva may be used for cortisol measurements with good
results, in situations where blood sampling is difficult to perform (Aardal and Holm,
1995).

According to Lundberg et al. (1994), cortisol level is a good and valid indicator
of stress and anxiety conditions. Kiess et al. (1995) have carried out a study in
Germany to measure the variety of saliva cortisol levels with age, pubertal state and
weight. They measured the salivary cortisol in 138 healthy infants, children and
adolescents and in 14 adults, at 8.00 am, 1.00 pm and 6.00 pm. They concluded that
cortisol levels are age-dependent. After 6 years old the values correlate significantly
with pubertal state. Cortisol levels also increase with body weight and body mass
index.
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 Master Thesis 2011

The samples were done at the beginning and at the end of the study during the
auditions day, always at the same time. It was used salivette with synthetic swab for
cortisol determination. Parents helped and supervised the sampling. The sampling was
done preferentially immediately after the child woke up, in sitting position and after
he/she washes the mouth with water. During the procedure, no one touches the cotton.
To obtain as much saliva as possible, child chewed the cotton during 2 minutes and
putted the cotton above the tongue during 3 more minutes. All the participants were
informed that children can`t use facial creams or lipstick, wash the teeth, use dental
floss, eat or drink nothing accept water before the sampling and they also cannot do
dental treatments 24h before the sampling. The samples were stored in the dark at
room temperature, and were taken to the laboratory after 72 hours.

3.4 Statistical analysis

All variables were analyzed to know if their decrease or increase were
statistically significant. The analyzes were done using SPSS 17.0. According to Fortin
(1999), it is very important to choose the right test to analyze the results. There are 2
types of tests that we can use to conduct a statistical analysis: parametric and non-
parametric tests. To use a parametric test the variables have to describe a normal
distribution of the population and samples must be independent and random. On this
study the samples are independent but they aren`t random. Non-parametric tests may
also be used when the sample is reduced, as our sample is constituted by 8 children in
each group, we must use a non-parametric test. Those are sufficient reasons to use a
non-parametric test. Non-parametric tests are less powerful than parametric tests since
the only condition is the independence of the measurements, although they are a good
alternative. A non-parametric test is also relatively insensible to extreme observations.

To analyze our data, the most appropriated test is the Mann-Witney test. The
Mann-Witney test is one of the most sensitive non-parametric tests and a great
alternative to t-test. The conditions to use the Mann-Witney test are: ordinal or
quantitative variables, independent samples and continuous variables (the values can
be divided).

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 Master Thesis 2011

4. Ethical Consideration

According to Fortin (1999), legally and ethically the minor participants cannot give
their informed consent, and this is therefore usually given by their parents or guardians.
However, if the children have the capacity to understand the purpose of the study, they
should be informed and their consent should be attached along with the consent of
their parents. All participants were informed about the aim of the study, its objectives
and procedures. The data was completely anonymous and confidential, used only by
the study investigator. The right of self-determination was respected, since the
participants and their legal representatives, as autonomous persons, were invited to
participate in the study (Fortin, 1999). The inclusion in this investigation was completely
voluntary and didn`t constitute any risk to the health of the children.

After providing a description of the study, a written informed consent was

obtained from the children and their legal representatives (4rd annex). In accordance
with Fortin (1999) "to obtain a written consent, free and clear of the subjects is
essential to the maintenance of ethical conduct in research". All ethical principles were
respected in this investigation: the right to self-determination, privacy, anonymity,
confidentiality, discomfort and injury (Fortin, 1999).

On 12th May of 2011, the Ethical Commission of University of Porto, analyzed

the proposal and gave and approval to the thesis, since all ethical principles were
respected. The document with this approval is in annex (5th annex).

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 Master Thesis 2011

5. Results

5.1 Data
The sample was divided into 2 similar groups of 8 children each. The Qigong
group was composed by 1 boy and 7 girls with a mean of 11.5 ( SD=0.7) years old, and
the control group was composed by 2 boys and 6 girls with 12 years old. Children of
the Qigong group were instructed to do the exercises every day during 7 weeks, and
they also were instructed to register when they do the exercises. Table 1 - Percentage
of days and assiduity to Qigong classesshows that percentage and their assiduity to
the classes.

Number of days Percentage Classes (max 14) Percentage

Student 1 15 30.6% 9 64.3%

Student 2 26 53.1% 13 92.9%

Student 3 43 87.8% 13 92.9%

Student 4 19 38.8% 11 78.6%

Student 5 15 30.6% 8 57.1%

Student 6 40 81.6% 12 85.7%

Student 7 45 91.8% 13 92.9%

Student 8 17 34.7% 11 78.6%

Table 1 - Percentage of days and assiduity to Qigong classes

Table 2 and Table 3 show the difference between the initial and the final results,
therefore a negative value means that the parameter gets worse, and a positive value
means that the parameter gets better. Table 2 shows the results of the Qigong group
and Table 3 shows the results of the control group. The last two lines of both tables
show the mean and the standard deviation of the respective values. The values of
EADS-C is the score obtained by the children, HR (heart rate) is represented in beats
per minute, BP (blood pressure) is represented in mm/Hg, SEMG (surface
electromyography) values are represented in mV per second, TR (time reaction) is
expressed in seconds and cortisol is expressed in g/dl. Integral values are presented

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 Master Thesis 2011

in annex 6. Blood pressure values were calculated by using the formula of mean blood
pressure (Ribeiro, Garcia, Fiori, 2007):
Systolic BP + (Diastolic BP x 2)
3

Qigong
EADS-C HR BP EMG TR Cortisol
group

Student 1 -1 12 12.33 0.0051 0.01633 -

Student 2 0 6 0.33 -0.0026 -0.009 0.131
Student 3 19 6 15.67 -0.0023 0.00967 0.5
Student 4 -1 5 7.33 -0.0036 -0.0103 0.311
Student 5 -1 3 -2.67 -0.0051 0.006 0.116
Student 6 3 17 -0.33 -0.0041 -0.027 0.125
Student 7 3 15 2.33 -0.0065 0.01567 -
Student 8 6 24 17.33 -0.0033 0.04833 0.404
Mean 3.5 11 6.54 -0.0028 0.00621 0.198
Standard
6.76123 7.2899 7.77 0.00347 0.02263 0.186
deviation
Table 2 - Difference between the 1st and the 2nd measurements (Qigong group)

Control
EADS-C HR BP EMG TR Cortisol
Group

Student 9 -13 -7 7.33 0.0023 0.019 -0.355

Student 10 9 -7 1.67 -0.0011 0.05167 -0.072
Student 11 3 13 9 -0.0018 0.01567 0.245
Student 12 4 -15 4 -0.0014 -0.0137 0.695
Student 13 -1 -8 8.67 -0.0033 0.09567 0.31
Student 14 2 -11 16.67 -0.0023 -0.027 0.025
Student 15 1 5 -3.33 -0.005 -0.0263 0.088
Student 16 3 -6 4.67 -0.0036 -0.0243 0.144
Mean 1 -4.5 6.04 -0.002 0.01133 0.135
Standard
6.3471 9.0711 5.81 0.00217 0.04408 0.306
deviation
Table 3 - Difference between the 1st and the 2nd measurements (control group)

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 Master Thesis 2011

Results show that subjective perception of anxiety and blood pressure

decreased in both groups, however the decrease was bigger in the Qigong group.
Heart rate decreased in the Qigong group and increased in the control group. Muscular
tension of trapezius muscle increased in both groups, however the increase was a little
bit bigger in the Qigong group. Time reaction decreased in both groups, however the
decrease was bigger in the control group.

During the development of the study, it was showed that thermography may be
a useful tool for objectifying Qigong related effects.

5.1 Statistical Analysis

The hypotheses to test are:

H0: The values to test are similar 1 = 2

H1: The values to test are different 1 2

The chosen is 0.05.

EADS-C

The data related to EADS-C in the Qigong and in the control groups is
represented on Figure 11.

Qigong group:
Mean: 3.5
Standard deviation: 6.76

Control Group
Mean: 1
Standard deviation: 6.35

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 Master Thesis 2011

Figure 11 - Mean and standard deviation of subjective perception of anxiety

H0: 1 = 2

H1: 1 2

p value = 0.959 (bilateral test)

As p values is superior to we can`t accept H0. This means that subjective

perception of anxiety isn`t statistically significant

Heart rate

The data related to heart rate in the Qigong and in the control groups is
represented on fFigure 12.

Qigong group:
Mean: 11
Standard deviation: 7.29

Control Group
Mean: -4.5

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 Master Thesis 2011

Standard deviation: 9.07

Figure 12 - Mean and standard deviation of heart rate

H0: 1 = 2

H1: 1 2

p value = 0.005 (bilateral test)

As p values is inferior to we accept H0. This means that heart rate decreasing
is statistically significant.

Blood pressure

The data related to blood pressure in the Qigong and in the control groups is
represented on Figure 13.

Qigong group:
Mean: 6.54
Standard deviation: 7.77

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 Master Thesis 2011

Control Group
Mean: 6.04
Standard deviation: 5.81

Figure 13 - Mean and standard deviation of blood pressure values

H0: 1 = 2

H1: 1 2

p value = 0.959 (bilateral test)

As p values is superior to we can`t accept H0. This means that blood pressure
decreasing isn`t statistically significant.

Surface Electromyography

The data related to surface electromyography in the Qigong and in the control
groups is represented on Figure 14.

Qigong group:
Mean: -0.0028
Standard deviation: 0.0035
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 Master Thesis 2011

Control Group
Mean: -0.002
Standard deviation: 0.0022

Figure 14 - Mean and standard deviation of surface EMG

H0: 1 = 2

H1: 1 2

p value = 0.195 (bilateral test)

As p value is superior to we can`t accept H0. This means that electromyography

increasing isn`t statistically significant.

Time reaction

The data related to time reaction in the Qigong and in the control groups is
represented on Figure 15.

Qigong group:
Mean: 0.00621
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 Master Thesis 2011

Standard deviation: 0.02263

Control Group
Mean: 0.01133
Standard deviation: 0.04408

Figure 15 - Mean and standard deviation of time reaction

H0: 1 = 2

H1: 1 2

p value = 1.00 (bilateral test)

As p values is superior to we can`t accept H0. This means that time reaction values
aren`t statistically significant.

Cortisol

The data related to salivary cortisol in the Qigong and in the control groups is
represented on Figure 16.

Qigong group

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 Master Thesis 2011

Mean: 0.198
Standard deviation: 0.186

Control Group
Mean: 0.135
Standard deviation: 0.306

Figure 16 - Cortisol levels

H0: 1 = 2

H1: 1 2

p value = 0.245 (bilateral test)

As p value is superior to we can`t accept H0. This means that cortisol values aren`t
statistically significant.

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 Master Thesis 2011

6. Discussion

Subjective perception of anxiety: EADS-C

According to our data, subjective perception of anxiety diminished in both

groups, however this decreasing was higher in the Qigong group than in the control
group. According to the same data, this difference between both groups isn`t
statistically significant.

Skoglund and Jansson (2006) have conducted a study in England, to

investigate the effects of Qigong on heart rate, blood pressure, finger temperature and
perceived stress in computer operators. The Qigong group (n=10) had daily sessions
of 30 minutes, from Monday to Friday, during 5 weeks and the control group (n=10)
continued with their usual daily work. The level of perceived stress rated by Borg`s
scale didn`t change during the 5 weeks in both groups.

In contrast Maldonado et al. (2005) have conducted a study in Spain, to

examine the effects of Qigong on subjective perception of anxiety and other
parameters, in university students (n=25). The Qigong group (n=13) completed a
program of 30 minutes of Qigong lessons, 5 times a week, and self-practice during the
weekends, during 1 month. Measurements were done at the begging and at the end of
the study. Results showed that Qigong group had significant (=0.05) lower anxiety
levels measured by Hamilton anxiety scale, than the control group.

Lee et al.1 (2004) have done a study to investigate the effects of Qigong on
subjective perception of anxiety, plasma concentrations of cortisol, and other
parameters. The Qigong group (n=16) completed a program of Qigong exercises daily,
during 4 weeks, 60 minutes per session. The Control group (n=16) also performed the
movements without gathering or moving Qi. Measurements were done at the beginning
and at the end of the program. The participants asked to the Spielber`s state-trait
anxiety, which includes 20 items to measure the acute level of anxiety. Results showed
that anxiety decreased 26% in the Qigong group and just 9% in the control group.
These results suggest that the movements used in Qigong could positively affect
anxiety states, however this effect is much smaller than that associated with Qi training.

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 Master Thesis 2011

In those three studies sampling was reduced as well as the time of Qigong
practice. The type of scale used is also different. There are studies defending that
Qigong can`t reduce subjective perception of anxiety, however there are also studies
defending that Qigong can significantly reduce this parameter. According to our study
Qigong can reduce subjective perception of anxiety in transverse flute schoolchildren
before auditions, however this decreasing isn`t significant comparing to the control
group.

Heart Rate

According to our data, heart rate decreased in the Qigong group and increased
in control group. The statistical analysis showed that this difference is significant for
=0.05.

Skoglund and Jansson (2006) have done a study, in England, to investigate the
effects of Qigong on heart rate (and other parameters) in computer operators. The
Qigong group (n=10) had daily sessions of 30 minutes, from Monday to Friday, during
5 weeks and the control group (n=10) continued with their usual daily work. Results
showed that heart rate was significant reduced in the Qigong group (=0.05).

In Hong Kong, Jones (2001) conducted a study to investigate the changes in

cytokine production, blood pressure, heart rate, blood cortisol level in healthy subjects
(n=19) practicing Guolin Qigong daily over 14 weeks. Measurements were taken
before training and after 3, 7 and 14 weeks. Results showed that heart rate decreased
but this difference isn`t significant.

According to those studies Qigong can diminish heart rate, however just one
concluded that this reduction is significant. According to our study Qigong helps to
reduce heart rate in a significant value. With those data we can conclude that Qigong
can reduce significantly heart rate in transverse flute schoolchildren before the
concerts.

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 Master Thesis 2011

Blood Pressure

Results show that blood pressure diminished in both groups, but this decreasing
was higher in the Qigong group. This difference isn`t statistically significant.

Lee et al. (2003) have carried out a study to determine the effects of Qigong on
blood pressure, and other parameters, in middle aged patients with essential
hypertension. The Qigong group (n=29) did 30 minutes of shuxinpingxuegong per day
during 10 weeks. Blood pressure was measured before and after 10 weeks. The
results showed that the levels of blood pressure were significantly smaller (=0.001) in
the Qigong group than in the control group (n=29). The examiners concluded that
Qigong helps to reduce blood pressure in middle aged patients with essential
hypertension.

Lee et al.2 (2004) have carried out a study to investigate the effectiveness of
Qigong on blood pressure and several blood lipids in hypertensive patients. Patients
were divided into Qigong group (n=17) and waiting-list control group (n=19). The
Qigong group completed a program of shuxinpingxuegong during 8 weeks, 30 minutes,
twice week. Measurements were done at the beginning and at the end of the study by
blood sampling and auscultation method. Results showed a significant decrease in
blood pressure in the Qigong group (=0,001). The authors concluded that Qigong
could reduce blood pressure and change lipid metabolism to health benefit.

In contrast, there was a study done by Skoglund and Jansson (2006), in

England, to investigate the effects of Qigong on blood pressure (and other parameters)
in computer operators. The Qigong group (n=10) had daily sessions of 30 minutes,
from Monday to Friday, during 5 weeks and the control group (n=10) continued with
their usual daily work. Results showed that Qigong had no effects on blood pressure.

In the same way, Jones (2001) carried out a study in Hong Kong to investigate
the changes on blood pressure (and other parameters) in healthy subjects (n=19)
practicing Guolin Qigong daily over 14 weeks. Measurements were taken before
training and after 3, 7 and 14 weeks. The results showed no significant changes on
systolic or diastolic blood pressure.

Another study was done by Maldonado et al. (2005), in Spain, to examine the
effects of Qigong on blood pressure (and other parameters) in university students
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 Master Thesis 2011

(n=25). The Qigong group (n=13) completed a program of 30 minutes of Qigong

lessons 5 times a week, and self-practice during the weekends, during 1 month.
Measurements were done at the begging and at the end of the study. Results showed
no significant differences between the 2 groups on blood pressure.

There are some studies defending that Qigong can positively influence blood
pressure but there are also some studies concluding that Qigong has no influence on
blood pressure. According to those findings also shuxinpingxuegong showed significant
influence on blood pressure values. According to our data we can conclude that
Qigong could help to diminish blood pressure values in transverse flute schoolchildren
before auditions, although this change isn`t significant.

Surface electromyography

According to our data, muscular tension of trapezius muscle, measured by

surface electromyography, increased in both groups. However those changes aren`t
significant, results showed a higher increase in the Qigong group than in the control
group.

According to Lundberg et al. (1994), the psychological stress increases

muscular tension of trapezius muscle measured by EMG. In the same way, Krantz,
Forsman and Lundberg (2004) affirm that psychological and physical stress increases
the muscular tension of the trapezius muscle, measured by SEMG. They also say that
there are an association between sympathetic arousal and muscular activity. Borini et
al. (2010) concluded that anxiety can influence electromyographic records even in non-
experimental situations. Also a review done by Conrad and Roth (2006) concluded that
anxiety increases the general muscular activity measured by SEMG.

According to those findings, we expected that muscular tension would be lower

after the Qigong program reflecting the decreased anxiety levels. According to Conrad
and Roth (2006) review patients suffering from anxiety disorders may have elevated
muscular tension, although they refer that the available evidence does not allow to
conclude that physiological activation decreases over the course of muscle relaxation
therapy, even when patients report becoming less anxious.

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 Master Thesis 2011

Studies of trapezius activity in response to a stressor agent showed that the

activity level increases more intensely when extra effort is induced by financial reward
or by increased task complexity (Bansevicius, Westgaard, Jesen, 1997). Also the
muscular activity is higher when stress situations are combined with some kind of
previous physical load (Lundberg et al, 1994). In another way, all those findings are
referring to adults and not to children. Those reasons could aid to understand our
results since children aren`t exposed to the same levels of stress as adults.

After this analysis we can affirm that in this preliminary study, Qigong wasn`t
effective in the reduction of muscular tension of trapezius muscle in transverse flute
schoolchildren before auditions, measured by SEMG.

Time reaction

Results showed that time reaction decreased in both groups, however this non-
significant decreasing was higher in the control group.

Anxiety, as a negative emotion, is frequently accompanied by changes in

cognitive processing. Attention deficit is often seen when subjects have to deal with
threat or stressed situations (Fales et al., 2008). According to those assumptions we
expected that Qigong group would have a more decreasing reaction time than the
control group, but this didnt happen. After this analyses we can`t conclude that Qigong
is effective on the reduction of time reaction of transverse flute schoolchildren before
auditions.

Cortisol

According to our data, cortisol levels decreased in both groups. This decreasing
was higher in the Qigong group, however this difference isn`t significant.

In Hong Kong, Jones (2001) has done a study to investigate the changes in
blood cortisol level, and other parameters, in healthy subjects (n=19) practicing Guolin
Qigong daily over 14 weeks. Measurements were taken before training and after 3, 7
and 14 weeks. This preliminary study indicates that blood levels of cortisol may be

58
 Master Thesis 2011

lowered by short-term practice of Qigong, however further studies are needed. In the
same way, in 2005, Maldonado et al. have conducted a study, in Spain, to examine the
effects of Qigong on the quantity of hormones, anxiety, blood pressure and subjective
quality of sleep in university students (n=25). The Qigong group (n=13) completed a
program of 30 minutes of Qigong lessons 5 times a week, and self-practice during the
weekends, during 1 month. Measurements were done at the begging and at the end of
the study. Results showed that the Qigong group had lower cortisol than control group,
however this difference isn`t significant.

From an opposing point of view, Lee et al.1 (2004) have done a study to
investigate the effects of Qigong on anxiety and plasma concentrations of cortisol,
ACTH and aldosterone. 32 men were divided into 2 equal groups. The Qigong group
completed a program of Qigong exercises daily, during 4 weeks. The exercises were
directed by a Qigong master during 60 minutes per session. The control group also
performed the movements without gathering or moving Qi. Measurements were done
at the beginning and at the end of the program using blood sampling. The results
showed that blood concentrations of ACTH, cortisol and aldosterone were significantly
smaller in the Qigong group than in the control group. In conclusion, those results
suggest that Qigong had a significant effect on hypothalamic-pituitary axis, which might
reflect stabilization of anxiety level.

All found studies conclude that blood cortisol diminish after Qigong lessons,
however just one concluded that this decreasing is significant. Our results showed that
cortisol levels could be lower after 7 weeks of Qigong practice, however this difference
isn`t significant.

The study confirms that Qigong related effects may be conventionally objectified
by psychological scores and physiological parameters including cortisol
measurements. In addition the study reveals that 2 new parameters can be chosen
such as EADS-C and capillary flow as measured by thermography.

Thermography as a real time objective functional assessment showed to be an

excellent tool for Qigong studies with highly significant measurability (data presented
within the master thesis of the engineer Luis Matos).

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 Master Thesis 2011

7. Conclusion

We can conclude that all the objectives were achieved. Although our data is
from a small sample size, the results we obtained are consistent with the hypothesis
that Qigong may positively influence anxiety levels of transverse flute schoolchildren,
aged 10 to 12, before the auditions. According to our data Qigong reduced subjective
perception of anxiety (measured by EADS-C), heart rate, blood pressure and salivary
cortisol levels in transverse flute schoolchildren before auditions, however only heart
rate decreasing is significant for an =0.05. In contrast, there are no evidences that
Qigong is effective in the reduction of muscular tension of trapezius (measured by
SEMG) and in the reduction of time reaction.

There are some obvious reasons for explaining those results. As we already
documented auditions took place on 17th March and on 6th May. If we analyze those
dates 17th March was a complicated date for all students because they were doing
tests at school. 6th May was 2 weeks after Easter holidays. It is probable that our
participants were under stressed situations at school during the first audition, and those
situations were solved during the second audition. This fact could change their anxiety
levels and influence the results.

Another reason that could influence our results is that all Qigong group follow
the expected program but unfortunately 5 students of the control group couldn`t be
present on the second audition date. For this reason we were forced to organize a third
audition on 19th May. The conditions of the first and of the second audition were the
same since the students played in a neutral place. The third audition was in Academia
de Msica de Paos de Brando, a familiar place for all students. Another different
aspect was the amount of public that attended to the audition since the first and the
second auditions had many more people than the third audition We were conscious
that those facts could influence the results but this was the only found solution to solve
the problem. Those facts could explain the decrease in time reaction in both groups
and the non-significant changes in the other parameters.

Another setback was hour of cortisol collecting. Ideally, the saliva sampling
should take place in the morning of the audition`s day, before breakfast. Unfortunately
in the first audition, 3 students of the control group forgot to do the measurement during
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 Master Thesis 2011

the morning. To solve this problem they did the measurement during the afternoon, at
the same hour in the first and in the last audition. In the second audition two of the
Qigong students forgot to do the measurement. To solve this problem we canceled the
first measurement and for this reason we just have 6 measurements of saliva cortisol in
the Qigong group and 8 in the control group.

Doing investigation with children is always a complicated task because some of

the children aren`t capable to understand the importance of this work. As we
presented before the percentage of days that children did the exercises varies between
30.6% and 91.8% and their attendance to the classes varies between 57.1% and
92.9%. Also the concentration and the responsibility during the exercises are very
important variables and impossible to measure. Those facts could also influence the
results.

As we have already documented, Academia de Msica de Paos de Brando

and Academia de Msica e Artes de Rio Meo were chosen because they are located
near Porto and they are convenient to the investigators. In the same way, children were
distributed to either the control group or the study group, according to their interest and
schedule to integrate Qigong classes. Because of those facts we can`t consider that
the sample is random. Our sample is too reduced and it can`t represent the population.
Those facts don`t allow the generalization of our results.

Variability between groups could also influence the results since the Qigong
group was composed by 1 boy and 7 girls with a mean of 11.5 ( s.d=0.7) years old, and
the control group was composed by 2 boys and 6 girls aged 12 years old. It is a
principal problem of Qigong research and psychological intervention to choose
adequate controls. In this pre-study we focused on measurability of the effects. The
control chosen here (waiting list design) may be changed to either another type of
Qigong, to another occupation or others. Proper randomization and blinding
procedures should be carried out to develop an objective study design.

Qigong effects can be measured properly by psychological scores and

physiological parameters such as salivary cortisol. This study shows 2 new objective
parameters (EADS-C, thermography) that may be used to a further document, the
obvious effects of the white ball Qigong on performance related anxiety and related
physical disorders as measured in this study.
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 Master Thesis 2011

8. Final considerations

Preliminary evidences support the hypothesis that Qigong can help to diminish
anxiety levels of transverse flute schoolchildren, aged 10 to 12, before the auditions
and that Qigong effects can be measured properly by psychological scores and
physiological parameters

According to our data Qigong reduced subjective perception of anxiety

(measured by EADS-C), heart rate, blood pressure and salivary cortisol levels in
transverse flute schoolchildren before auditions, however only heart rate decrease is
significant for an =0.05. In contrast, there are no evidences that Qigong is effective in
the reduction of muscular tension of trapezius (measured by SEMG) and in the
reduction of time reaction.

This is regarded as a first step towards the creation of objective study designs
to be systematically planned on the basis of measurability of Qigong related effects. To
our knowledge, there are so far no scientific studies on performance related anxiety
and Qigong at all.
Qigong is a good alternative to pharmacological treatment to reduce anxiety
levels, since it isn`t expensive, it is easy to do and can be practiced at all the time.
Furthermore, the exercise system of the white ball is effective. The main advantage of
this system is the fact that an exercise cycle only takes a few minutes and requires only
little movement and space, so it could be integrated in class-teaching without
significant loss of teaching time.

As our results can`t be generalized further well controlled studies might be

needed, with a representative and random sample.

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 Master Thesis 2011

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DORCAS, A., YOUNG, P. 2003. Qigong: harmonizing the breath, the body and the
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LEAL et al. 2009. Estudo da escala de depresso, ansiedade e stresse para crianas
(EADS-C). Psicologia, sade e doenas. 10(2), 277-284

LEE, MS, et.al. 2003. Effects of Qigong on blood pressure, blood pressure
determinants and ventilatory function in middle-aged patients with essential
hypertension. American journal of Chinese medicine. ?,?

LEE, MS, et al.1 2004. Effects of Qi-training on anxiety and plasma concentration of
cortisol, ACTH, and aldosterone: a randomized placebo-controlled pilot study. Stress
and health. 20, 243-248

LEE, MS, et al.2 2004. Effects of Qigong on blood pressure, high-density lipoprotein
cholesterol and other lipid levels in essential hypertension patients. International journal
of Neuroscience. 114. 777-786

LI, M., CHEN, K., MO, Z. 2002. Use of Qigong therapy in the detoxification of heroin
addicts. Alternative Therapies. 8:1, 1-9

LOVIBOND, LOVIBOND. 1995. The structure of negative emotional states:

Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck
Depression and Anxiety Inventories. Behaviour Research and Therapy. 33(3), 335-343

LUNDBERG et al. 1994. Psychophysiological stress and EMG activity on the trapezius
muscle. International journal of behavioral medicine. 1(4). 354-370

MALDONADO et al., 2005. Efectos de la prtica de Qigong sobre parmetros

hormonales, sintomas de ansiedad, presin arterial y calidad subjetiva de sueo en
estudiantes universitarios. Cuadernos de medicina psicosomtica y psiquiatria de
enlace. 76/77. 9-14

MENEZES et al, 2007. Resistncia ao tratamento nos transtornos de ansiedade: fobia

social, transtorno de ansiedade generalizada e transtorno de pnico. Revista brasileira
de psiquiatria. 29(II), 55-60

OH, B. et. al. 2010. Impact of medical Qigong on quality of life, fatigue, mood and
inflammation in cancer patients: a randomized controlled trial. Annals of Oncology. 21:
608-614

65
 Master Thesis 2011

RIBEIRO, GARCIA, FIORI. 2007. Determinao da presso arterial em recm-

nascidos. Scientia Medica. 17:3. 156-167

RIBEIRO, HONRADO and LEAL. 2004. Contribuio para o estudo da adaptao

portuguesa das escalas de ansiedade, depresso e stress (EADS) de 21 itens de
Lovibond e Lovibond. Psicologia, Sade e doenas. 5(2), 229-239

SANCIER, KM. 1996. Medical applications of Qigong. Alternative therapies. 2:1. 40-46

SANCIER, KM. 1999. Therapeutic benefits of Qigong exercises in combination with

drugs. Journal of alternative and complementary medicine. 5:4. 383-389

SANCIER, KM. HOLE, L. 2001. Qigong and neurologic illness. Alternative and
complementary treatments in neurologic illness. 15. 197-220

SKOGLUND, L., JANSSON, E. 2007. Qigong reduces stress in computer operators.

Complementary Therapies in Clinical Practice. 13, 78-84

TSANG, HW, et. al. 2003. The effects of Qigong on general and psychosocial health of
elderly with chronic physical illnesses: a randomized clinical trial. International journal
of geriatric psychiatry. 18. 441-449

TRKER. 1993. Electromyography: some methodological problems and issues.

Physical therapy. 73 (10). 698-710

WATSON et al.1, 1995. Testing a Tripartite Model: I, Evaluating the Convergent and

Discriminant Validity of Anxiety and Depression Symptom Scales. Journal of Abnormal

Psychology. 104 (1). 3-14

WATSON et al.2, 1995. Testing a Tripartite Model: II. Exploring the Symptom Structure
of Anxiety and Depression in Student, Adult, and Patient Samples. Journal of Abnormal
Psychology. 104 (1). 15-25

WILSON, SMITH and HOLMES. 2007. The role of effort in influencing the effect of
anxiety on performance: Testing the conflicting predictions of processing efficiency
theory and conscious processing hypothesis. British Journal of Psychology. 98. 411-
428

66
 Master Thesis 2011

WITT, CMD, et. al. 2005. Qigong for schoolchildren: a pilot study. The journal of
alternative and complementary medicine. 11:1. 41-47

WITT, CMD, et. al. 2007. Xianggong (`fragrant` Qigong) for the health of school
children: a qualitative pilot study of feasibility and effects. Journal of Chinese medicine.
84. 46-51

67
 Master Thesis 2011

1st Annex: Schedule

2010 2011

Activity

November

December

February
January

March

June
April

May

July
Literature research

Development of the project

Data collection

Data analysis

Writing the thesis

68
 Master Thesis 2011

2nd Annex: Literature review

Authors, Experi
Control
Title mental Method / Intervention Results / Conclusion
year group
group

AARDAL, E. Cortisol in saliva- Satisfactory precision of the analysis and the

and HOLM. references ranges and The concentrations were determined in simple non-invasive sampling procedure
A. n= 197 matched samples of saliva and serum suggest that saliva may be used for cortisol
relation to cortisol in
serum collected at 8am and 10pm. measurements in situations where blood
1995
sampling is difficult to perform.
ANDREATI Tratamento
NI, farmacolgico do In Brazil, just 50% of all patients with anxiety
LACERDA tratamento de ansiedade Literature review. disorders get completely cured with western
and FILHO. generalizada: drugs.
2001 perspectivas futuras
Participants were exposed to a two-
BANSEVICI choice reaction-time test for 1 hour. EMG
Mental stress of long-
US, MD, recordings were performed bilaterally
duration: EMG activity, It is concluded that the mean level of the EMG
WESTGAA over the frontalis, temporalis, splenius,
perceived tension, fatigue n=36 response is of little consequence for pain
RD, RH, and trapezius muscles. Pain and
and pain development in development during stressful conditions.
JENSEN C. perceived tension were scored on a
pain-free subject
1997. visual analogic scale, and fatigue on a
Borg scale.

BORGES et Ansiedade e coping em Children between 10 and 13 years old show

n=196 Measure anxiety by multidimensional
al. crianas e adolescentes: more anxiety in some aspects like separation
anxiety scale for children and the coping
diferenas relacionadas and afraid of being alone in strange situations.
69
 Master Thesis 2011

2008 com a idade e gnero responses inventory- youth. On the other hand girls show more anxiety than
boys in aspects like tension, somatic
symptoms, perfectionism, fear of failing,
separation, and anxiety in general.
Simultaneous bilateral mastication,
habitual mastication and voluntary
contraction in maximum intercuspation
Anlise da influncia da were performed on three different days,
BORINI et ansiedade sobre o sinal n=16 with an interval of one week between Anxiety can influence electromyographic
al. 2010 eletromiogrfico. them. The variables activation time and records even in non-experimental situations.
maximum intensity were calculated to
analyze the electrical activity of
superficial part of the masseter and
anterior part of the temporal muscles.
Qigong may improve immune function, increase
CHEN, K., microcirculation, raise the pain threshold and
YEUNG, R. Exploratory studies of The authors reviewed more than 50
survival rate; Qigong and its curative effect on
2002 Qigong therapy for studies about Qigong therapy for cancer
cancer have demonstrated consistent results
cancer in China in China.
for inhibitory effect on cancer growth and
China metastasis in clinical observation.
The authors used a non-linear system
identification technique, known as When principal dynamic modes and spectral
CHOI and Using heart rate monitors
n=3 principal dynamic modes, to predict the features are combined, system discriminates
OSUNA, to detect mental stress activation level of the two autonomic stressful events with a success rate of 83%
2009
branches: sympathetic and within subjects (69% between subjects).
parasympathetic.
Biopsychosocial effects Pharmacological treatment could have side
CHOW, Y., of Qigong as a mindful effects such as nausea, vomits and addiction.
TSANG, H. exercise for people with Literature review. Qigong could be considered as an alternative
2007 anxiety disorders - A therapy for those suffering from anxiety
speculative review disorders.

COLE et al., A Longitudinal Look at 330 3 year longitudinal study and every 6 Results show that high levels of anxiety predict
70

1998 the Relation Between students
Depression and Anxiety
in Children and
parents
Adolescents
CONRAD Muscle relaxation therapy
and ROTH. for anxiety disorders: it
2006 works but how?
DORCAS, Qigong: harmonizing the
A., YOUNG, breath, the body and the
P. 2003 mind
Anxiety and cognitive
efficiency: differential
FALES et modulation of transient
al. 2008 and sustained neural
activity during a working
memory task
Sensitivity of trapezius
electromyography to
HANSSON differences between work
et al. 2000 tasks influence of gap
definition on
normalization methods
JONES, B. Changes in cytokine
M. 2001 production in healthy
subjects practicing Guolin
Master Thesis 2011
months parents and students completed
depression and anxiety questionnaires.
228
Literature review.
Literature review.
The investigators used a magnetic
resonance imaging design to track
transient and sustained activity in
n=96
dorsolateral prefrontal cortex, while high
and low anxious participants performed a
working memory task.
Bilateral trapezius EMG was recorded,
for a full workday for the participants
n=58
following both maximal and submaximal
reference contractions.
2 hours of Guolin Qigong per day during
n=19 None 14 weeks; Blood pressure, pulse rate,
blood cortisol level and production of
71
high levels of depression in children and
adolescents.
Although patients suffering from anxiety and
panic disorders may exhibit elevated muscle
tension, abnormal autonomic and respiratory
measures during laboratory baseline
assessments, the available evidence does not
allow to conclude that physiological activation
decreases over the course of muscle relaxation
therapy in those patients, even when patients
report becoming less anxious.
Qi Gong helps to harmonize the mind, the
breath and the body. However from a western
point of view, the methodology of the reviewed
studies is weak.
Results showed that high and low anxious
individuals make strikingly different use of
cognitive and default-network circuitry during
performance of a cognitive task.
Normalization to submaximal, rather than
maximal contractions, improved sensitivity to
differences between tasks, and reduced
undesirable variability.
No significant changes in blood pressure but
the pulse rate decreased such as cortisol;
results show that Qigong improves the stress-
 Master Thesis 2011

Hong Kong Qigong: a pilot study cytokines were measured before training coping skills of the participants, however further
and after 3, 7 and 14 week. studies are needed.

The use of The data came from a nationally

complementary and
KESSLER, alternative therapies to
et al. 2001 n= 2055
treat anxiety and
depression in the United
States
Salivary cortisol levels
KIESS et al. throughout childhood and
1995 adolescence: relation n=152
with age, pubertal, stage
and weight
Consistency in
KRANTZ,
physiological stress
FORSMAN
responses and
and
electromyographic
LUNDBERG
activity during induced
2004
stress exposure in
women and men
Estudo da escala de
LEAL et al. depresso, ansiedade e
n=361
2009 stresse para crianas
(EADS-C)
Effects of Qigong on
LEE, MS,
blood pressure, blood
et.al. 2003 pressure determinants
and ventilatory function in
representative survey of 2,055
respondents (19971998) that obtained
information on the use of 24
complementary and alternative therapies
for the treatment of specific chronic
conditions.
The authors measured salivary cortisol in
138 healthy infants, children and
adolescents and in 14 adults, at 8.00 am,
1.00 pm and 6.00 pm.
The aim of this study is to compare the
different physiological stress responses
n=21 and trapezius muscle activity (measured
by SEMG) during mental and physical
stress.
The authors adapted the language of the
original EADS, to children giving an
example of the respective situation.
Children answer to the scale in individual
session and Cronbach Alpha was
calculated.
Qigong group did 30 minutes of
n=29 n=29 shuxinpingxuegong per day during 10
weeks; blood pressure, urinary
catecholamines, forced vital capacity and
72
Complementary and alternative therapies are
used more than conventional therapies by
people with self-defined anxiety attacks and
severe depression.
Cortisol levels are age-dependent: after 6 years
old the values correlate significantly with
pubertal state. Cortisol levels also increase with
body weight and body mass index.
The association between sympathetic arousal
and muscle activity is of importance for
understanding the high prevalence of
musculoskeletal disorders in mentally stressful
but physically light work tasks. Psychological
and physical stress increases the muscular
tension of trapezius muscle, as well as the
incidence of musculoskeletal disorders.
The results obtained suggest that this scale
might be of importance to this population.
Although further studies are needed to evaluate
the scale's sensitivity.
Blood pressure and catecholamines were
smaller in the Qigong group than in the control
group; lung function improved in the Qigong
group. Results indicate that Qigong has

middle-aged patients with
essential hypertension
Effects of Qi-training on
anxiety and plasma
LEE, MS, et
concentration of cortisol,
1
al. 2004
ACTH, and aldosterone:
a randomized placebo-
controlled pilot study
Effects of Qigong on
blood pressure, high-
LEE, MS, et
density lipoprotein
2
al. 2004
cholesterol and other lipid
levels in essential
hypertension patients
LI, M.,
CHEN, K., Use of Qigong therapy in
MO, Z. 2002 the detoxification of
heroin addicts
China
Master Thesis 2011
forced expiratory volume per sec were relaxation effects and stabilizes the sympathetic
measured before and after 10 weeks. nervous system in patients with essential
hypertension.
The Qigong group completed a program
of exercises daily, during 4 weeks, 60
minutes per session. The control group
performed the movements without
Results showed that anxiety decreased 26% in
gathering or moving Qi. Plasma cortisol,
n=16 n=16 the Qigong group and just 9% in the control
ACTH and aldosterone were measured
group.
at the beginning and at the end of the
study. The participants also asked to the
Spielber`s state-trait anxiety to measure
the acute level of anxiety.
The Qigong group completed a program
of shuxinpingxuegong during 8 weeks, Results showed a significant decreased of
n=17 n=19 30 minutes twice week. Blood pressure blood pressure, HDL, total cholesterol and
and lipid levels were measured at the apolipoprotein A1 in the Qigong group.
beginning and at the end of the study.
Qigong group: 2 to 2,5 hours of Pan Gu
Qigong an received Qi adjustments from
a Qigong master during 10 to 15 minutes
n=26 daily during 10 day.
(medicati
Medication group: detoxification drug Results suggest that Qigong may be an
on
n=34 during 10 days using gradual reduction effective alternative for heroin detoxification
group)
method. without side effects.
n=26
Control group: received only basic care
(control)
and medications to treat several
symptoms like pain, diarrhea and sleep
disorders; urine morphine test,
electrocardiogram, withdrawal syndrome
73
 Master Thesis 2011

evaluation scale and Hamilton anxiety

scale were used before and during the
10 days of intervention.
The structure of negative
emotional states: The authors administered the Beck
LOVIBOND, The DASS was demonstrated satisfactory
Comparison of the Depression Inventory and the Beck
LOVIBOND. psychometric proprieties: 0,81 correlation to
Depression Anxiety n=717 Anxiety Inventory to the participants, and
1995 Beck Anxiety Inventory and 0,74 to Beck
Stress Scales (DASS) compared the results with the DASS
Depression Inventory.
with the Beck Depression scores.
and Anxiety Inventories
Psychological stress plays a role in
Subjects were individually exposed to musculoskeletal disorders by increasing
LUNDBERG Psychophysiological muscular tension in low-load work situations
mental arithmetic, the stroop color word
et al. 1994 stress and EMG activity n=62 and in the absence of physical load. It is also
test, the cold pressor test and
on the trapezius muscle indicated that the stress-induced increase in
standardized test contractions.
muscular tension is accentuated on top of a
physical load.
Qigong group completed a program of 30
minutes of Qigong lessons 5 times a
Efectos de la prtica de week, and self-practice during the Results showed no significant differences
MALDONA Qigong sobre parmetros weekends, for 1 month. The evaluation between the 2 groups in blood pressure and
DO et al. hormonales, sintomas de of blood cortisol, ACTH, TSH and PTH, subjective quality of sleep. However the Qigong
ansiedad, presin arterial n=12 n=13 blood pressure, anxiety (Escala de group had lower cortisol, ACTH and anxiety
2005 y calidad subjetiva de ansiedad de Hamilton and Inventario de levels than the control group which suggests
sueo en estudiantes ansiedad de Beck) and subjective quality that the regular practice of Qigong may inhibit
universitrios of sleep (Cuestionario de calidad the hypothalamic-pituitary-adrenal axis.
subjetiva de Pittsburg) took place at the
beginning and at the end of the study.
Resistncia ao Western medicine can`t solve all cases of
MENEZES
tratamento nos Literature review. anxiety disorders since a great number of
et al, 2007 transtornos de patients fail to respond or remain with clinically
ansiedade: fobia social, significant residual symptom after the

74
 Master Thesis 2011

transtorno de ansiedade treatment: one out of three patients shows

generalizada e transtorno insufficient response or does not get better with
de pnico standardized western treatment.

Impact of medical Qigong Qigong group received usual medical

OH, B. et. on quality of life, fatigue, care and attended a Qigong program Results showed that Qigong significantly
al. 2010 mood and inflammation during 10 weeks, 90 minutes per week; improve quality of life, fatigue, mood
n=83 n=79
in cancer patients: a Quality of life, fatigue and mood status disturbances and inflammation in cancer
Australia randomized controlled were measured at the beginning and at patients.
trial the end of the study.
Blood pressure measurement in newborn
RIBEIRO, Determinao da should be performed preferentially in the right
GARCIA, presso arterial em Literature review. upper arm, with cuff size corresponding to 40%
FIORI. 2007 recm-nascidos of the circumference of the upper arm and that
involves 80% to 100% of the respective
extremity.
Contribuio para o
RIBEIRO, estudo da adaptao
HONRADO portuguesa das escalas The DASS was firstly translated and then Results show a structure identical to the original
and LEAL. de ansiedade, depresso n=200 the cognitive debriefing was done. The Australian version, with the same items in the
2004 e stresse (EADS) de 21 Cronbach Alpha was calculated. same scale.
itens de Lovibond e
Lovibond
SANCIER, Medical applications of Studies show that Qigong can beneficially affect
Literature review.
KM. 1996 Qigong many functions of the body and improve health.
Studies suggest that Qigong may affect many
Therapeutic benefits of Approximately 1000 references about functions of the body, permit reduction of the
SANCIER,
Qigong exercises in medical applications of Qigong were dosage of the drugs required for health
KM. 1999
combination with drugs reviewed. maintenance and provide greater health
benefits than using drug therapy alone.
SANCIER, Qigong can effectively complement western
Qigong and neurologic The investigators used 126 references
KM; HOLE, medicine. Studies report that Qigong decreases
75
 Master Thesis 2011

L. illness about Qigong and its effects. the drug dosage of asthma and hypertension
patients and assists detoxification heroin
2001
addicts, beyond other effects.
USA
The Qigong group had daily sessions of Qigong reduces heart rate, finger temperature
SKOGLUN 30 minutes, from Monday to Friday, and noradrenaline in urine. There were no
D, L., during 5 weeks; Heart rate, blood effects on blood pressure and on the level of
JANSSON, Qigong reduces stress in
n=10 n=10 pressure and finger temperature were perceived stress. Results show that Qigong
E. 2007 computer operators
measured at the beginning and at the reduces the activity of sympathetic nervous
England end of the working day as well as the system and may reduce stress in computer
perceived of stress. operators.
The effects of Qigong on 1 hour practice of Qigong, twice a week,
TSANG, general and psychosocial during 12 weeks; results were measured Qigong improves physical health, psychological
HW, et. al. health of elderly with with different scales and questionnaires and social development of elderly people,
2003 n=25 n=25
chronic physical to measure: the degree of depression, reducing the degree of depression and
China illnesses: a randomized the state of physical, psychological and increasing their quality of life.
clinical trial social, quality of life and self-concept.
SEMG is usually more susceptible to artifacts
than IEMG. It is possible, however, to make
Electromyography: some useful recordings with appropriated surface
TRKER electrodes and special precautions must be
methodological problems Literature review.
1993 taken. Intramuscular electrodes may be
and issues
preferred for recording the activity of small
peripheral muscles or muscles located deep
within the body.
Testing a Tripartite The tripartite model was tested by General distress, anhedonia vs. positive affect,
Model: I, Evaluating the conducting separate factor analyses of somatic anxiety, emerged in each data set,
WATSON et Convergent and the 90 items in the Mood and Anxiety suggesting that the symptom structure in this
1 n=5 Symptom Questionnaire which was domain is highly convergent across diverse
al. , 1995 Discriminant Validity of
Anxiety and Depression designed to assess the hypothesized samples. These factors broadly corresponded
Symptom Scales symptom groups, together with other to the symptom groups proposed by the
symptom and cognition measures. tripartite model.

76
 Master Thesis 2011

Testing a Tripartite
Model: II. Exploring the The tripartite model was tested by The same 3 factors (general distress,
WATSON et Symptom Structure of conducting separate factor analyses of anhedonia vs. positive affect, somatic anxiety)
2 n=5 emerged in each data set, suggesting that the
al. , 1995 Anxiety and Depression the 90 items in the Mood and Anxiety
in Student, Adult, and Symptom Questionnaire. symptom structure in this domain is highly
Patient Samples convergent with the proposed model.

The role of effort in Mid-handicap golfers made a series of

influencing the effect of putts to target holes under two
WILSON, anxiety on performance: counterbalanced conditions designed to
Processing efficiency theory and the conscious
SMITH and Testing the conflicting manipulate the level of anxiety
n=18 processing hypothesis offer useful theoretical
HOLMES. predictions of processing experienced. The effort exerted on each
frameworks for examining the relationship
2007 efficiency theory and putting task was assessed though self-
between anxiety and performance in sport.
conscious processing report, psychophysiological (heart rate
hypothesis variability) and behavioral (pre-putt time
and glances at the target) measures.
Qigong group received xiang-gong
Qigong influences positively grades and social
lessons over 6 months, twice a week,
WITT, CMD, behavior of the children; qualitative analysis
during 15 (Level 1) or 25 minutes (level
et. al. Qigong for indicated a relevant decrease in individual
2); teachers, parents and children
schoolchildren: a pilot n=45 n=45 complains for some children in the Qigong
2005 answered standardized questionnaires at
study group; Qigong helps to improve social behavior
the beginning and at the end of the
and grades but further studies are needed to
study; the 5 teachers also answered
generalize these results.
semi-structured in-depth interviews.
Xiang-gong lessons, twice a week,
WITT, CMD, Xianggong (`fragrant`
during 15 (Level 1) or 25 minutes (level Results showed that Qigong helps to enhance
et. al. Qigong) for the health of
2) over 6 months; semi-structured in- vitality and community strength and also social,
school children: a n=140 None
2007 depth interviews were conducted with the psychological and in some cases medical
qualitative pilot study of
participating teachers at the end of the improvement.
feasibility and effects
study.

77
 Master Thesis 2011

3rd Annex: EADS-C

Escala de ansiedade, depresso e stresse para crianas de 21 itens (Lovibond e

Lovibond)

Nome: _____________________________________________ Data: __/__/__

Por favor l cada uma das afirmaes abaixo e assinala 0, 1, 2, ou 3 para indicar
quanto cada afirmao se aplicou a ti durante a semana passada.
No h respostas certas ou erradas. No leves muito tempo a indicar a resposta em
cada afirmao.

Aplicou-se Aplicou-se
No se Aplicou-se a
a a
aplicou mim a maior
mim mim
nada a parte das
algumas muitas
mim vezes
vezes vezes

1. Tive dificuldades em acalmar-

0 1 2 3
me
2. Senti a boca seca 0 1 2 3
3. No consegui sentir nenhum
sentimento bom. Por ex. No
0 1 2 3
consegui
parar de chorar
4. Senti dificuldade em respirar 0 1 2 3
5. Tive dificuldade em tomar
iniciativa para fazer coisas. Por ex.
0 1 2 3
No me apeteceu ver televiso,
estudar e nem jogar computador.
6. Tive tendncia a reagir em
demasia em determinadas
situaes. Por ex. apeteceu-me 0 1 2 3
bater num(a) colega que no se
calava na aula.
7. Senti tremores. Por ex., nas
0 1 2 3
mos, nas pernas.
8. Senti que estava a utilizar muita
0 1 2 3
energia nervosa.
9. Preocupei-me com situaes
em que podia entrar em pnico e
0 1 2 3
fazer figura ridcula. Por ex. Ter
muito medo, ficar muito assustado

78
 Master Thesis 2011

e, todos os meus amigos

perceberem e gozarem comigo.
10. Senti que no tinha nada a
esperar do futuro. Por ex. Que
0 1 2 3
nada do que eu sonho, se podia
tornar realidade.
11. Dei por mim a ficar agitado 0 1 2 3
12. Senti dificuldade em relaxar.
Por ex. No conseguia estar 0 1 2 3
sentado, parado e quieto.
13. Senti-me desanimado/cansado
0 1 2 3
e melanclico/tristonho.
14. Estive intolerante em relao a
qualquer coisa que me impedisse
de terminar aquilo que estava a
fazer. Como por ex. Faltar a luz, 0 1 2 3
no conseguir terminar o jogo de
computador e, ficar muito irritado e
resmungo.
15. Senti-me quase a entrar em
pnico ou seja, tive medo e fiquei 0 1 2 3
muito assustado.
16. No fui capaz de ter
entusiasmo por nada. Por ex. nem
0 1 2 3
jogar computador ou ver televiso
eu tinha vontade
17. Senti que no tinha muito valor
como pessoa ou seja, senti-me 0 1 2 3
pouco importante.
18. Senti que, por vezes estava
sensvel.
0 1 2 3
Por ex. Tive muita vontade de
chorar de repente
19. Senti alteraes no meu
corao sem fazer exerccio fsico.
0 1 2 3
Por ex., o corao comeou a
bater muito depressa, de repente
20. Senti-me assustado sem ter
tido uma boa razo para isso. Por
0 1 2 3
ex. Fiquei cheio de medo sem ter
acontecido nada.
21. Senti que a vida no tinha
sentido. Por ex. Parece que de
0 1 2 3
repente, as coisas deixaram de
valer a pena.

Muito obrigada pela tua participao!

79
 Master Thesis 2011

4th Annex: Declaration of Informed consent

DECLARAO DE CONSENTIMENTO

Designao do estudo

EFFECTS OF QIGONG ON ANXIETY ON PERFORMANCE RELATED ANXIETY AND

PHYSIOLOGICAL STRESS FUNCTIONS IN TRANSVERSE FLUTE MUSIC
SCHOOLCHILDREN A FEASIBILITY STUDY

Objectivo

Conhecer o efeito do Qigong na ansiedade, performance e funes relacionadas

com stresse de alunos de flauta transversal com idades compreendidas entre os 10
e os 12 anos, antes de audies.

Eu, abaixo-assinado,

_______________________________________________________ BI: _____________

Representante legal de:

_______________________________________________________ BI: _____________

DECLARO:

Que percebi a explicao que me foi fornecida acerca da investigao que se

tenciona realizar, bem como do estudo em que serei includo.

Que me foi dada oportunidade, antes de prestar o meu consentimento assinando

no presente documento, de fazer as perguntas que julguei necessrias investigadora
Cludia Maria Gomes de Sousa, de quem obtive todas as respostas de forma satisfatria.

Que tomei conhecimento de que, de acordo com as recomendaes da

Declarao de Helsnquia, a informao que me foi prestada versou os objectivos, a
metodologia, as intervenes a realizar no estudo de interveno, os benefcios e

80
 Master Thesis 2011

inconvenientes previstos, os riscos potenciais e o eventual desconforto.

Que me foi dada a informao que todas as intervenes so simples de realizar

e no produzem efeitos prejudiciais sade dos intervenientes.

Que compreendi que a participao voluntria e que tenho o direito de retirar o

meu educando a todo o tempo da investigao, sem ter de prestar explicao e sem que
isso possa ter como efeito qualquer prejuzo.

Alm disso, que me foi garantido que toda a informao pessoal e todos os dados
recolhidos no decorrer do estudo sero mantidos confidenciais.

Por isso, presto meu consentimento livre, informado e esclarecido.

Santa Maria da Feira, ___ de ____________ de 20__

Assinatura do representante legal:

_______________________________________________________________________

Assinatura do participante menor:

_______________________________________________________________________

Assinatura do investigador:

_______________________________________________________________________

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 Master Thesis 2011

5th Annex: Ethical permission

COMISSO DE TICA

PARECER N. 14/CEUP/2011

PARECER DA COMISSO DE TICA DA UNIVERSIDADE DO PORTO SOBRE O

PROJECTO INTITULADO:

EFFECTS OF QIGONG ON ANXIETY, PERFORMANCE AND PHYSIOLOGICAL

STRESS FUNCTIONS IN TRANSVERSE FLUTE MUSIC SCHOOLCHILDREN

SUBMETIDO POR: CLUDIA MARIA GOMES DE SOUSA

Data de entrada do pedido: 2011.04.20

Relator: Professora Doutora Maria Fernanda Bahia

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 Master Thesis 2011

12 Maio 2011
Objectivo do projecto: realizao da tese de mestrado sob o ttulo The influence of
Qigong on the anxiety of music school children before auditions and concerts.

Metodologia: recrutamento de estudantes de flauta transversal, com idades entre 10 e

12 anos, para o estudo do efeito do exerccio de Qigong sobre a ansiedade manifestada,
antes das audies e concertos. Com base na bibliografia, dado o conceito de Qigong e
indicado o tipo de exerccio a efectuar (movimentos fsicos, respiratrios, massagem e
meditao). assegurado o ensino do Qigong, bem como as instrues para a prtica
dos exerccios dirios, no domiclio. especificada a dimenso e so indicados os
critrios de incluso e de excluso da amostra.

Comentrios:

1. Atravs do plano enviado (anexo 1), o trabalho encontra-se j na fase de recrutamento

da amostra (8 estudantes Qigong e 8 estudantes para grupo controlo). Pode inferir-se
que esta prtica ter a responsabilidade partilhada entre a mestranda (licenciada em
fisioterapia pela Universidade de Aveiro) e representantes das escolas de msica
referidas, no projecto, como parceiras.

2. O estudo de investigao est bem objectivado e definido no que respeita a mtodos

de trabalho (concretizao do tempo, condies e determinaes especficas que iro
permitir avaliar os efeitos e fundamentar concluses). No sentido de suporte cientfico e
orientao, conta a declarao do Coordenador do curso de Mestrado em Medicina
Tradicional Chinesa, os nomes dos orientadores e o apoio tcnico).

3. Preocupaes ticas: dada a idade dos estudantes a recrutar, deve ser sempre
considerado simultaneamente no processo de consentimento informado o termo
de consentimento informado assinado pelos representantes legais, mas tambm o
assentimento dos participantes, uma vez que pressuposto o entendimento do
objectivo do estudo, por todos os envolvidos.

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 Master Thesis 2011

4. Deve estar especificada no termo de consentimento informado a garantia de

confidencialidade, nomeadamente a destruio dos dados aps a concluso do
estudo.

Os representantes legais devem ficar com uma cpia do termo de consentimento,

que deve ser assinado por eles e pelo investigador.

Concluso: A CEUP d parecer favorvel realizao deste estudo, desde que

sejam integralmente cumpridas as recomendaes acima explicitadas.

Universidade do Porto, 12 de Maio de 2011

O Presidente O Relator

Prof. Doutor Jorge Sequeiros Profa. Doutora Maria Fernanda Bahia

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 Master Thesis 2011

6th Annex: Results

First results

Qigong BP Mean
EADS-C HR BP MAX BP MIN EMG TR 1 TR 2 TR 3 Cortisol
group

Student 1 5 133 109 80 89.67 0.01401 0.245 0.281 0.274 -

Student 2 1 100 121 84 96.33 0.00678 0.31 0.309 0.232 0.464
Student 3 26 98 135 91 105.67 0.00469 0.312 0.277 0.243 0.55
Student 4 14 95 106 77 86.67 0.00505 0.283 0.256 0.231 0.437
Student 5 17 99 112 77 88.67 0.00823 0.274 0.234 0.245 0.442
Student 6 13 85 99 72 81 0.00663 0.305 0.3 0.234 0.547
Student 7 5 95 115 72 86.33 0.0043 0.288 0.301 0.262 -
Student 8 12 148 134 88 103.33 0.00684 0.273 0.316 0.21 0.836

Control
EADS-C HR BP MAX BP MIN BP mean EMG TR 1 TR 2 TR 3 Cortisol
group

Student 9 45 87 105 71 82.33 0.00862 0.298 0.32 0,268 0.147

Student 10 19 80 117 71 86.33 0.00441 0.334 0.45 0,223 0.102
Student 11 10 100 117 79 91.67 0.00712 0.293 0.28 0,233 0.522
Student 12 13 69 117 75 89 0.00576 0.264 0.223 0,215 0.798
Student 13 23 83 123 70 87.67 0.00542 0.371 0.371 0,313 1.53
Student 14 9 80 96 76 82.67 0.00495 0.209 0.196 0,143 0.066
Student 15 5 77 97 68 77.67 0.00408 0.249 0.272 0,27 0.179
Student 16 9 73 107 75 85.67 0.00545 0.224 0.22 0.164 0.303

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 Master Thesis 2011

Second results

Qigong
EADS-C HR BP MAX BP MIN BP mean EMG TR1 TR2 TR3 Cortisol
group

Student 1 3 121 94 69 77.33 0.00891 0.247 0.263 0.241 -

Student 2 1 94 124 82 96 0.0094 0.299 0.32 0.259 0.333
Student 3 7 92 118 76 90 0.00703 0.283 0.273 0.247 0.05
Student 4 15 90 100 69 79.33 0.00862 0.297 0.25 0.254 0.126
Student 5 18 96 116 79 91.33 0.01333 0.25 0.243 0.242 0.326
Student 6 10 68 92 76 81.33 0.01071 0.319 0.295 0.306 0.422
Student 7 2 80 112 70 84 0.01081 0.257 0.309 0.238 -
Student 8 6 124 114 72 86 0.0101 0.216 0.225 0.213 0.432

Control
EADS-C HR BP MAX BP MIN BP mean EMG TR1 TR2 TR3 Cortisol
group

Student 9 45 94 97 64 75 0.00632 0.299 0.277 0.253 0.502

Student 10 10 87 110 72 84.67 0.00548 0.29 0.246 0.211 0.174
Student 11 7 87 106 71 82.67 0.0089 0.279 0.286 0.194 0.277
Student 12 9 84 105 75 85 0.00712 0.277 0.245 0.221 0.103
Student 13 24 91 107 65 79 0.00873 0.297 0.275 0.196 1,22
Student 14 7 91 101 49 66.33 0.0072 0.232 0.226 0.171 0.041
Student 15 4 72 109 67 81 0.00906 0.3 0.301 0.269 0.091
Student 16 6 79 101 71 81 0.00902 0.245 0.232 0.204 0.159

86